Medical Questionnaire

General Queries

First Name: Marital Status:
Last name: Occupation:
Date of birth: Height (cm) / Weight (kg):
Intervention you have in mind: Your email address:
Tel. number: Country of residence:

 

Past Medical History

Diabetes Mellitus
type:
 
Asthma
type/medication:
 
High blood pressure
how long/medication:
 
Heart disease
explain ...
 
Liver disease
explain ...
 
Kidney impairment
explain ...
 
Bleeding disorders
explain ...
 
Deep vein thrombosis (DVT)
explain ...
 
Allergies
explain ...
 
Skin disorders
explain ...
 
Infectious disorders (Hepatitis, HIV)
 
   
Previous operations
explain ...
 
Previous anaesthesia
any problems..
 
Previous long-term hospitalization
 
   

 

Pregnancy

Could you be pregnant?
Previous pregnancies
Number of children
Mode of child birth

 

Drug History

Regular medications
Any current medication?
Any known drug allergies?
Any herbal / over the counter medication?

 

Family History

Any history of bleeding disorders if yes, explain:
Any history of breast disorders if yes, explain:
Any history of other disorders if yes, explain:

 

Current Medical History

Are you currently seeking any active form of treatment?

 

Social History

Smoking if yes how many daily:
Alcohol    if yes how many units weekly:
Recreational drugs if yes how often:
Exercise level
Home circumstance
 
Attach picture (optional):

 

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