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Medical Questionnaire

Identification Information
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Hospitalization Information
Have you ever been hospitalized?:

If yes, list the year and reason for each hospitalization.
















Primary Care Physician Information






Surgery Information
Have you been advised to have surgery that you have declined?:



HAVE YOU HAD ANY SURGERIES/OPERATIONS?
(For each "Yes", please provide details in the associated field.)
On your back, arm, leg or knee?:
  
To treat a hernia?:
  
Varicose Veins?:
  
Other operations?:
  
Allergy Information
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Serious allergy?:
  
Bad Reaction to any medication?:
  
Advised not to take any medication?: (i.e. Aspirin)
  
Skin Information
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Hives/Eczema or rash?:
  
Chronic Skin Problems?: (i.e. Cuts Slow to Heal)
  
Excessive Skin Dryness?:
  
Problems with easy bruising?:
  
Chemical or jewelry rash/sensitivity?:
  
Neuro Information
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
A psychiatric or emotional problem?:
  
Numbness/Weakness/Paralysis?:
  
Dizziness or fainting spells?:
  
Severe/Frequent migraine headaches?:
  
Headinjury, concussion or skull fracture?:
  
Neurological Disorders?:
  
Seizures or blackouts?:
  
Stroke?:
  
Ear/Eye Information
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Hearing Loss?:
  
Frequent ear infections?:
  
Ringing in ears?:
  
Other Ear Problems?:
  
Glaucoma or cataracts?:
  
Red eyes?:
  
Eye injury/vision loss?:
  
Other eye problems?: (i.e., Strain from VDT Use)
  
Glasses/contacts?:
  
  
Head/Neck Information
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Recent problems with teeth or dentures?:
  
Frequent mouth ulcers/infections?:
  
Sinus problems or hay fever?:
  
Frequent sore throats?:
  
Frequent nose bleeds?:
  
Trouble with thyroid?:
  
Problem requiring radiation treatment in the neck area?:
  
  
Lungs Information
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Asthma or wheezing?:
  
Coughed up blood?:
  
Shortness of breath without apparent reason?:
  
TB or positive test for TB?:
  
Pneumonia or Pleurisy?:
  
Do you cough every day?:
  
Pain or tightness in chest?:
  
More than 3 episodes of bronchitis in 1 year?:
Ever smoked tobacco in any form?:
  



Had a chest x-ray?:
  
Heart Information
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Rheumatic fever or heart murmur?:
  
Heart Disease?:
  
Treated for heart condition?:
  
Unusually cold or bluish colored hands or feet?:
  
High blood pressure?:
  
How is it treated?:  
Elevated Cholesterol?:
  
Anemia or any blood disease?:
  
Phlebitis, varicose veins, or blood clots/poor circulation?:
  
Chest pain with activity?:
  
GI Information
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Ulcers?:
  
Hiatal Hernia?:
  
Indigestion, pain or unusual burning in stomach?:
  
Vomiting of blood?:
  
Bloody/Tarry Bowel Movements?:
  
Colitis or nervous stomach?:
  
Yellow jaundice or hepatitis?:
  
Problems with your pancreas?:
  
Gallbladder Disease?:
  
Kidney Information
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Bladder or kidney disease?:
  
Kidney stones?:
  
Burning or discomfort on urination or frequent urination?:
  
Hernia?:
  
Blood in urine?:
  
Fasting Blood Sugar Information
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Diabetes or elevated blood sugar?:
  
Cancer of any kind?:
  
Muscle/Skeleton Information
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Arthritis, rheumatism, neck, back or spine injury or disease?:
  
Been treated for a back problem?:
  
Recurrent stiffness or back pain?:
  
Bursitis, tendonitis?:
  
Recurrent pulled muscles or sprains?:
  
Hand or wrist injury or problems?:
  
Hip or knee injury or problem?:
  
Ankle or foot injury or problem?:
  
Frostbite?:
  
Job requiring heavy lifting or standing or sitting long periods?:
  
Any broken bones?:
  
For Females Only
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Menstrual Irregularities?:
  
Recurrent problems of the female organs?:
  
Breast masses or lumps?:
  
Do you practice monthly breast self exams?:
  
  
  
For Males Only
HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE?
(For each "Yes", please provide details in the associated field.)
Prostate or testicular problems?:
  
Breast tenderness, swelling or lumps?:
  
Do you practice monthly testicular self exams?:
  
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