confidential

Health Questionnaire

Name______________________________________________________ Age__________ Height________ Weight_______

Have you ever had, or do you now have, any of the following? If you answer “yes,” explain further..

1. Severe headaches rNo rYes _______________________________________________________

2. Eye trouble rNo rYes _______________________________________________________

3. Ear trouble rNo rYes _______________________________________________________

4. Allergies/Hay fever rNo rYes _______________________________________________________

5. Thyroid disorder rNo rYes _______________________________________________________

6. Asthma rNo rYes _______________________________________________________

7. Other lung or breathing problems rNo rYes _______________________________________________________

8. High blood pressure rNo rYes _______________________________________________________

9. Heart trouble rNo rYes _______________________________________________________

10. Trouble with arteries/veins rNo rYes _______________________________________________________

11. Bleeding/Clotting problems rNo rYes _______________________________________________________

12. Anomia/Sickle cell trait rNo rYes _______________________________________________________

13. Kidney/Bladder problems rNo rYes _______________________________________________________

14. Stomach/Duodenal ulcer rNo rYes _______________________________________________________

15. Hepatitis/Other liver problems rNo rYes _______________________________________________________

16. Gall Bladder/Pancreas problems rNo rYes _______________________________________________________

17. Intestinal disorders rNo rYes _______________________________________________________

18. Haemorrhoids/Rectal problems rNo rYes _______________________________________________________

19. Parasites rNo rYes _______________________________________________________

20. Hernia rNo rYes _______________________________________________________

21. Prostate/Testicle problems rNo rYes _______________________________________________________

22. Uterus/Ovary problems rNo rYes _______________________________________________________

23. Arthritis/Bursitis rNo rYes _______________________________________________________

24. Back trouble/Sciatica rNo rYes _______________________________________________________

25. Other joint problems rNo rYes _______________________________________________________

26. Epilepsy rNo rYes _______________________________________________________

27. Other neurological disorders rNo rYes _______________________________________________________

28. Fainting spells rNo rYes _______________________________________________________

29. Recurring dizziness rNo rYes _______________________________________________________

30. Mental/Nervous conditions rNo rYes _______________________________________________________

31. Skin conditions/Chronic rash rNo rYes _______________________________________________________

32. Disorder of the immune system rNo rYes _______________________________________________________

33. Rheumatic fever rNo rYes _______________________________________________________

34. Tuberculosis/Positive T.B. test rNo rYes _______________________________________________________

35. Malaria rNo rYes _______________________________________________________

36. Diabetes rNo rYes _______________________________________________________

37. Tumour/Cancer rNo rYes _______________________________________________________

38. Blood transfusions rNo rYes _______________________________________________________

39. Physical handicaps rNo rYes _______________________________________________________

40. Have you ever received

psychotherapy? rNo rYes _______________________________________________________

41. Are you currently under a

doctor’s care? rNo rYes _______________________________________________________

42. Have you ever had any serious

illness or injury? rNo rYes _______________________________________________________

43. Do you smoke? rNo rYes _______________________________________________________

44. Other____________________________________________________________________________________________

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List medications (prescription/non-prescription) you currently take:_______________________________________________

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Have you ever been hospitalized for any illness, injury or operation? rNo rYes

If “Yes” please list, giving reasons and dates:_________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

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When was the date of your last…?

Physical Examination ( dd / mm / yyyy ) Dental Examination ( dd / mm / yyyy ) Tetanus Booster ( dd / mm / yyyy )

In case of illness or accident, whom should we notify? (next of kin)

Name_______________________________________________________________________________________________

Street Address________________________________________________________________________________________

Town_____________________________________________ State_____________________________________________

Post Code_____________ Country____________________________ E-Mail______________________________________

Phone (H)_____________________________ (W)_____________________________ Fax__________________________

I, (please print full name clearly) _____________________________________________________ , hereby declare that the information presented is complete, honest and accurate.

Signature__________________________________________ Date______________________________________________