Medical History Questionnaire

help us understand your case

Enable to better understand your condition and consider the best treatment, we'll need you to fill in this medical questionnaire.

 

All information will be kept confidential and will be exclusively used for the evaluation of your health, please try to make it as accurate and complete as possible. You might consult your doctor and request his/her help filing it. Please take your time and complete it carefully and thoroughly, and then review it to be certain you have not left anything out.

 

If you have questions or concerns, we will help you with those after this form is completed. We realize that some parts of the form will be unclear to you. Do your best to complete the form. Your questions will be thoroughly addressed afterwards. It might be helpful for you to keep a written list of questions or concerns as you complete the medical history form.

 

Paper Form

If you prefer to fill paper form, Click Here to download the Medical History Questionnaire, fill it and e-mail us a scan copy.

Online Form

Personal Information

Your Name (required)

Your Email (required)

Country (required)

Address (required)

Contact Phone (required)

Secondary Phone (optional)

Birth Date (required)

Marital Status (required)

Sex: (required)

Education (optional)

Other

 

Family Physician and/or Primary Health Care Provider (optional sections)

Doctor/Other

Contact Phone

Address

May I send a copy of your consultation to your physician or primary health care provider and consult with them as necessary? (required)

 

Present Medical History (optional section)

Check those questions to which you answer yes (leave the others blank)

Has a doctor ever said your blood pressure was too high?


Do you ever have pain in your chest or heart?


Are you often bothered by a thumping of the heart?


Does your heart often race?


Do you ever notice extra heartbeats or skipped beats?


Are your ankles often badly swollen?


Are your ankles often badly swollen?


Do cold hands or feet trouble you even in hot weather?


Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary?


Do you suffer from frequent cramps in your legs?


Do you often have difficulty breathing?


Do you get out of breath long before anyone else?


Do you sometimes get out of breath when sitting still or sleeping?


Has a doctor ever told you your cholesterol level was high?


Has a doctor ever told you that you have an abdominal aortic aneurysm?


Has a doctor ever told you that you have critical aortic stenosis?


 

Do you now have or have you recently experienced:

Chronic, recurrent or morning cough?


Episode of coughing up blood?


Increased anxiety or depression?


Problems with recurrent fatigue, trouble sleeping or increased irritability?


Migraine or recurrent headaches?


Swollen or painful knees or ankles?


Swollen, stiff or painful joints?


Pain in your legs after walking short distances?


Foot problems?


Back problems?


Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation or diarrhea?


Significant vision or hearing problems?


Recent change in a wart or a mole?


Glaucoma or increased pressure in the eyes?


Exposure to loud noises for long periods?


An infection such as pneumonia accompanied by a fever?


Significant unexplained weight loss?


A fever, which can cause dehydration and rapid heart beat?


A deep vein thrombosis (blood clot)?


A hernia that is causing symptoms?


Foot or ankle sores that won’t heal?


Persistent pain or problems walking after you have fallen?


Eye conditions such as bleeding in the retina or detached retina?


Cataract or lens transplant?


Laser treatment or other eye surgery?


 

Women only answer the following. Do you have:
Menstrual period problems?


Significant childbirth - related problems?


Urine loss when you cough, sneeze or laugh?


Are you on any type of hormone replacement therapy?


 

Men and women answer the following:

List any prescription medications you are now taking:

List any self-prescribed medications, dietary supplements, or vitamins you are now taking:

Date of last complete physical examination:

Date of last chest X-ray:

Date of last electrocardiogram (EKG or ECG):

Date of last dental check up:

List any other medical or diagnostic test you have had in the past two years:

List hospitalizations, including dates of and reasons for hospitalization:

List any drug allergies:

 

Past Medical History
Check those questions to which your answer is yes (leave others blank) Heart attack if so, how many years ago?


Rheumatic Fever


Heart murmur


Diseases of the arteries


Varicose veins


Arthritis of legs or arms


Diabetes or abnormal blood-sugar tests


Phlebitis (inflammation of a vein)


Dizziness or fainting spells


Epilepsy or seizures


Stroke


Diphtheria


Scarlet Fever


Infectious mononucleosis


Nervous or emotional problems


Anemia


Thyroid problems


Pneumonia


Bronchitis


Asthma


Abnormal chest X-ray


Other lung disease


Injuries to back, arms, legs or joint


Broken bones


Jaundice or gall bladder problems


 

Family Medical History
Father:

A) If Alive

My father's general health is:

(If Poor) Reason for poor health:

Current Age

 

B) If Deceased

Cause of death:

Age at death

 

Mother:

A) If Alive

My mother's general health is:

(If Poor) Reason for poor health:

Current Age

 

B) If Deceased

Cause of death:

Age at death

 

Siblings:

Number of brothers

Number of sisters

Age range

Health problems (if any)

 

Familial Diseases

Have you or your blood relatives had any of the following (include grandparents, aunts and uncles, but exclude cousins, relatives by marriage and half-relatives):

Heart attacks under age 50


Strokes under age 50


High blood pressure


Elevated cholesterol


Diabetes


Asthma or hay fever


Congenital heart disease (existing at birth but not hereditary)


Heart operations


Glaucoma


Obesity (20 or more pounds overweight)


Leukemia or cancer under age 60


 

Other Heart Disease Risk Factors
Smooking

Have you ever smoked cigarettes, cigars or a pipe? (If no, skip to diet section)

If you did or now smoke cigarettes, how many per day?

Age started

If you did or now smoke cigars, how many per day?

Age started

If you did or now smoke a pipe, how many pipefuls a day?

Age started

If you have stopped smoking, when was it?

If you now smoke, how long ago did you start?

 

Diet

What do you consider a good weight for yourself? (in kilograms)

What is the most you have ever weighed (women: including when pregnant)? (in Kilograms)

How old were you?

One year ago my weight was: (in kilograms)

At age 21 my weight was: (in kilograms)

Number of meals you usually eat per day:

 

Number of times per week you usually eat the following:

Beef

Fish

Desserts

Pork

Fowl

Fried Foods

 

Do you ever drink alcoholic beverages?

If yes, what is your approximate intake of these beverages?

Beer:

If often

Wine:

If often

Hard Liquor:

If often

 

At any time in the past, were you a heavy drinker (consumption of six ounces of hard liquor per day or more)?

Do you usually use oil or margarine in place of high cholesterol shortening or butter?

Do you usually abstain from extra sugar usage?

Do you usually add salt at the table?

Do you eat differently on weekends as compared to weekdays?

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