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Medical Questionnaire

* Indicates a required field.
Identification Information
(last 4 digits)
Hospitalization Information
Have you ever been hospitalized?:

Primary Care Physician Information
Surgery Information
Have you been advised to have surgery that you have declined?:
(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?:
(For each "Yes", please provide details in the associated field.)
Allergy Information
Serious allergy?:
Bad Reaction to any medication?:
Advised not to take any medication?:
Skin Information
Hives/Eczema or rash?:
Chronic Skin Problems?:
Excessive Skin Dryness?:
Problems with easy bruising?:
Chemical or jewelry rash/sensitivity?:
Neuro Information
A psychiatric or emotional problem?:
Dizziness or fainting spells?:
Severe/Frequent migraine headaches?:
Head injury, concussion or skull fracture?:
Neurological Disorders?:
Seizures or blackouts?:
Ear/Eye Information
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):
Head/Neck Information
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
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
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
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
Bladder or kidney disease?:
Kidney stones?:
Burning or discomfort on urination or frequent urination?:
Blood in urine?:
Fasting Blood Sugar Information
Diabetes or elevated blood sugar?:
Cancer of any kind?:
Muscle/Skeleton Information
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?:
Job requiring heavy lifting or standing or sitting long periods?:
Any broken bones?:
For Females Only
Menstrual Irregularities?:
Recurrent problems of the female organs?:
Breast masses or lumps?:
Do you practice monthly breast self exams?:
For Males Only
Prostate or testicular problems?:
Breast tenderness, swelling or lumps?:
Do you practice monthly testicular self exams?:
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