Medical Questionnaire
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- Wilfrid Walsh
- 6 years ago
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1 MEDICIS Health Testing Center Avenue de Tervueren Bruxelles Tel : 2/ Medical Questionnaire Name :. Maiden name : First name :. Sex :. Address : Phone (private) : Office :. Date of birth : Nationality :... Employer : Profession : General practitioner :. The purpose of this questionnaire is to obtain an insight into your state of health and to provide the doctor with information about it. Please complete this questionnaire carefully at home and bring it with you the day of your medical screening.. If your answer is, please check and give any information which you might consider useful in the column marked «details». If your answer is «NO», leave the space blank. 1
2 FAMILY HISTORY Did or does a member of your family suffer from any of the following conditions? F 1 Sudden death 2 Heart attack 3 Cerebrovascular accident (stroke) 4 High bloodpressure 5 Angina pectoris 6 Artritis 7 Diabetes 8 Gout (uric acid) 9 Bowel cancer 1 Stomach cancer 11 Lung cancer 12 Breast cancer 13 Gynaecological cancer 14 Gallstones 15 Kidney stones 16 Asthma PERSONAL ANTECEDENTS Have you been treated or hospitalised for: P 1 Lungs 2 Heart 3 Blood vessels 4 Nervous system 5 Stomach or bowels 6 Kidney and urinary tract 7 Liver 8 Gyn. problems 9 Endocrine glands 1 Infection 11 Bone or joints 12 Congenital problems 13 Lumps 14 Other 2
3 P 15 Were there problems during your pregnancies? 16 Have you ever had more than two weeks sickleave? 17 Did you have any surgery? 18 Did you ever have chemotherapy, radiotherapy, or have you ever been treated with hormones? 19 Were you ever victim of an accident? 2 Have you ever had a blood transfusion? 21 Has an anomaly been found in a previous screening? 22 Have you spent any time in tropical countries? 23 Are you allergic to any substance? WAY OF LIVING - HABITS 1 Do you consider yourself in bad health? 2 Are you married? 3 Are you divorced? 4 Do you have children? 5 Do you sleep well? 6 Do you smoke? 7 Do you regularly drink alcohol? 8 Do you drink more than 5 cups of coffee a day? 9 Do you eat a lot of sweets? 1 Do you eat a lot of meat, eggs, cheese or butter? 11 Are you on a diet? 12 Do you wish dietary advice? 3
4 13 Do you take any medication - sleeping pills? - transquilizers? - antidepressives? - antihypertensives? - heart pills 14 Do you take any drugs? 15 Are you working full time? 16 Do you have a hobby? 17 Do you have social activities? GENERAL QUESTIONS 18 Are you feeling tired? 19 Have you lost or gained weight? 2 Have you lost your appetite? 21 Do you sometimes have an unexplained temperature? 22 Do you have unexplained pains? 23 Are you sweating abnormally? CARDIOVASCULAR AND PULMONARY SYSTEM 24 Are you short of breath - at rest? - during exercice? - during the night? - after the meals? 25 Do you feel a tightness of the chest? 26 Do you have palpitations? 27 Do you regularly suffer from swollen feet? 28 Do your legs hurt while walking? 4
5 29 Do you suffer of a feeling of heaviness in the legs? 3 Do you have varicose veins? 31 Are the fingers easily white, blue or painful? 32 Do you often cough? 33 Do you frequently have phlegm? With blood, green? 34 Do you often have bronchitis? 35 Are you wheezing? 36 Do you have asthma? GASTRO INTESTINAL SYSTEM 37 Do you regularly have abdominal pain? 38 Do you have nausea, are you often vomiting? 39 Do you have irregular stool? With blood, black? 4 Are you intolerant towards certain foods? 41 Do you have digestive problems? 42 Do you have hemorrhoïds? URO GENITAL SYSTEM 43 Do you have problems with urinating? 44 Do you have to urinate during the night? 45 Do you have to urinate more frequently recently? 46 Do you have bloody urine? 47 Are the testicles painfull or swollen? 48 Do you have a problem with the penis 5
6 GYNAECOLOGICAL SYSTEM 49 Are you completed menopause? 5 Are the menses irregular? 51 Do you lose blood between the menses? 52 Are the breasts swollen before the periods? 53 Have you noticed a outflow of the breasts? 54 Have you noticed any nodule in the breasts? 55 Have you abnormal vaginal discharge? 56 Are the sexual intercourses painful? 57 Do you have any vulvar problems (itching, ulcers, ) 58 Do you use any contraceptive? NEUROLOGICAL SYSTEM 59 Do you have dizziness? Do you have syncopes? 6 Do you have pricking sensations in arms and legs? 61 Have you noticed a loss of sensibility? 62 Have you noticed a loss of muscular strength? 63 Do you have tremors? 64 Do you have problems with the - balance? - speech? - memory? 65 Did or do you have convulsions? 66 Do you regularly have headaches? 67 Have you noticed any changes in your personality? 6
7 E.N.T. 68 Are there any hearing problems in your family? 69 Do you have problems with the ears? (ringing in the ears) 7 Have you noticed a loss of hearing? 71 Do you bleed from the nose? 72 Do you have a chronic nasal or postnasal drip? 73 Do you have problems with the mouth, tongue or throat? 74 Have you noticed a hoarseness lately? 75 Do you have problems swallowing? BONE AND JOINTS 76 Do you have morning stiffness in the joints? 77 Do you have joint pain while exercising? 78 Do you have back pains? 79 Do you easily have bone fractures? 8 Do you have a history of muscular,joint or ligament problems? 81 Do you have neckpains? 82 Do you have muscular cramps during exercise? 83 Do you have pain in arms or legs? E AND SKIN 84 Do you have a skin problem? 85 Has a beauty mark or mole changed recently (growing, itching, bleeding, ) 7
8 86 Do you lose your hair? 87 Do you easily have skin rashes, itching, acne? 88 Do you feel some tension or pain in the eyes? 89 Are the eyes itchy, prickly 9 Has your vision changed lately? 91 Is your color vision normal? 92 Do you have a vision problem? Are you wearing glasses? BLOOD, IMMUNITY AND ENDOCRINE GLANDS 93 Are you bleeding easily? 94 Do you easily have bruises? 95 Have you noticed the presence of swollen lymph glands? 96 Do you frequently have infections? 97 Do these infections cure easily? 98 Do you sneeze easily? 99 Do you have hay fever? 1 Do you have any allergy towards : - drugs? - food? - others? 8
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Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation
Island Acupuncture & Massage Therapy Patient General Information GENERAL PATIENT INFORMATION Last Name First Name Home Phone Cell Phone Work Phone Email Address (street) (city) (state) (zip) Date of Birth
Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
New Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist
Patient Intake Form for Acupuncture Treatment at Infinite Healing
Section A: Your Information Patient Intake Form for Acupuncture Treatment at Infinite Healing Last Name: First Name: Middle Initial: Mailing Address: _ City: Postal Code: E-mail: Birth date: M D YR Age:
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
MEDICAL QUESTIONNAIRE
Center for Restorative Pelvic Medicine MEDICAL QUESTIONNAIRE Dear Patient: Please take a few minutes to complete this form. This will help assure you of the best possible care and will be held in confidence