Health Screening Questionnaire - medicalliance.co.uk

1 1 Health Screening Questionnaire Please complete all the sections in the Questionnaire . The information is used to obtain an accurate description of your lifestyle and history that will provide valuable information for your Health screen. The information provided in the Questionnaire is treated as strictly confidential and is not passed to any other person or organisation other than MedicAlliance medical staff. MedicAlliance Limited and MedicAlliance Healthcare Limited 1 The Manor House, Little Horwood Manor, Little Horwood, Buckinghamshire MK170PU Tel: 01296 711006 Fax 01296 711041 Patient Name and Contact Details First Name Last Name Telephone Mobile Email 2 Patient Name Number Booking No.

2 To enable us to assess your Health status and potential Health needs, please complete this Questionnaire as fully as you can and bring it with you to your Health Screening appointment. Please answer all the questions and do not leave any blank as the information you provide will give us valuable insight into your lifestyle and Health status. If any questions are unclear, please mark them and bring them to our attention during your consultation. 1. Administration 2. Personal Details Title Surname Forename Date of Birth GP s Name and address Postcode Home address Postcode Marital status Married Single Divorced Living with partner Separated Gender Male Female No.

3 Of children Sex and ages of children 3. Current Medical Symptoms Please tick Yes or No for each symptom that you may have suffered from recently or currently experience: Please expand on any yes answers in the space provided below, or on last page. Visual Disturbances Yes No Hearing difficulties Yes No Chronic productive cough (> 3 months) Yes No Wheezing Yes No Coughing up blood Yes No Chest pain/angina Yes No Fainting/blackouts/dizzy spells Yes No Shortness of breath Yes No Palpitations Yes No Calf pain with exercise Yes No Swollen ankles Yes No Frequent thirst or urination Hoarseness Yes No Yes No Excessive weight gain or loss Loss of appetite Yes No Yes No Change in bowel habits Rectal bleeding Yes No Abdominal cramps Yes No Yes No Regular headaches/migraines Yes No Pins and needles Yes No Muscle weakness Yes No Depression/anxiety Yes No Difficulty in initiating urination Yes No

4 Post urination dribble Yes No Poor urinary stream Yes No Pain on urination Yes No Blood in your urine Yes No Have you noticed any new spots on your skin? Yes No Have any moles changed colour, size, shape or started bleeding? Yes No Symptoms not mentioned or associated Health SCREEN Questionnaire For office use only Employer address Job title Employer name If you have personal medical insurance (PMI), please confirm the name of your provider and your policy number. Date of appointment Time of appointment PMI Company Policy number 3 4. Medical History Patient Name Number Booking No.

5 Do you have or have you had: If yes, give dates and details: High cholesterol levels? A stroke or aneurism? Lung conditions? Bronchitis, asthma, pneumonia, pleurisy, shortness of breath or any other problems? Digestive conditions? Indigestion, heartburn, flatulence, gastric/duodenal ulcer, constipation, diarrhoea, piles/haemorrhoids, bleeding from the bowel?

6 Heart conditions? Chest tightness/pain, high blood pressure, heart attack, angina, circulatory or other problems? Genitourinary problems? Testicular, prostate, urinary tract, genital, kidney infection or other problems? Nervous system problems? Muscular weakness, loss of sensation, numbness or tingling, paralysis, blackouts, fits, epilepsy, migraine, significant headaches or other problems? For office use only Conditions of the ear, nose and throat? Sore throat, cold, ear infections, sinusitis, Hearing or other problems? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Allergic conditions?

7 Hay fever, drug, food or other allergies? Eye problems? Eye strain, double/blurred vision, infection, glaucoma, cataract or other problems? Endocrine gland problems? Diabetes, thyroid or other problems? Blood problems? Anaemia, bruising easily, lymph gland, or other problems? Bone, muscle, joint problems? Rheumatism, arthritis, sciatica, low back, neck, shoulder or other joint or limb problems? Yes No Yes No Yes No Yes No Yes No 4 Patient Name Number Booking No.

8 If yes, give dates and details: Skin conditions? Contact dermatitis, eczema, psoriasis, acne or other conditions? Have you consulted your during the last year? If yes why? Are you currently taking any medically or self prescribed medication? Have you taken any medication during the last year? Have you had any serious illness, injuries or accidents?

9 Have you ever been referred to a specialist for investigation, or had any operations? Have you ever had a chest X-ray? If yes, when and why? 4. Medical History (continued) Mental Health problems? Sleep difficulties, stress, panic attacks, anxiety, depression, nervous breakdown, referral to psychiatrist/counsellor, or other problems? Do you have any family history of significant Health problems? High blood pressure, heart attack, stroke, diabetes, glaucoma, osteoporosis, cancer? 5. Family History Are your siblings still alive? If yes, what are their ages? If no, what was the cause of their death?

10 Brothers Sisters Brothers Sisters Brothers Sisters Are you parents alive? If yes, what are their ages? If no, what was the cause of their death? How old where they when they died Mother Father Mother Father Mother Father For office use only Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 5 Patient Name Number Booking No. 6. Past Gynaecological History (For female patients only) 7. Health Habits Do you experience: Tick Yes or No No Burning during urination Yes Frequent urination Yes No Vaginal discharge Yes No Bleeding between periods Yes No Bleeding post sex Yes No Are you pregnant Yes No Date of last menstrual period DD MM YYYY Duration of period (days) Age of menarche (first period) Number of pregnancies Number of live births Year of last PAP smear Year of last Mammogram Self breast examination Yes No Have you stopped menstruating?