Medical Questionnaire (Internal Medicine)/

1 english / .. ID . Medical Questionnaire (Internal Medicine)/ . Please check the appropriate . year month day Patient name/ Date/ . / / / . Date of birth/ year/ month/ day/ Sex/ Male/ Female/ . Height and weight/ cm kg Age/ years old/ . Language/ Nationality/ . Living condition/ . With family member(s) who require nursing care/ Have young children/ . Aged household/ Living alone/ Single parent/ . Other/ ( ). Employment/ . Full-time/ Part-time/ Self-employed/ . Retired/ Unemployed/ . What symptoms do you have?/ . Headache/ Dizziness/ Dry mouth/ . Sore throat/ Cough/ Palpitation/ . Chest pain/ Chest discomfort/ Stomachache/ . Nausea/ Vomiting/ Shortness of breath/ . Diarrhea/ Abdominal bloating/ Abdominal pain/ . Bloody stools/ Fever/ Rash/ . High blood pressure/ Cannot sleep/ Lack of energy/ . Easily fatigued / Weight loss/ Loss of appetite/.

2 Shaking/shivering/ ( Involuntary movements/ Coldness/ ). Swelling of the whole body/ Swelling in part of the body/ . Swelling with inflammation/ Numbness/tingling/ Other/ ( ). When did the symptoms start?/ . Since approximately: year/ month/ day/ . Are you currently undergoing treatment for any diseases?/ . Yes/ (Disease/ : ). No/ . Are you allergic to any foods or medications?/ . Yes/ Medication/ Food/ Other/ ( ). No/ . Are you currently taking any medications?/ . Yes/ Please show us the medications if you have them with . No/ . *Please fill in the reverse side of the all pages as well, where . 1/2. 2014 . english / .. ID . Have you previously had any of the diseases listed below?/ . Gastrointestinal disease/ Liver disease/ Heart disease/ . Kidney disease/ Respiratory disease/ Blood disease/ . Brain / neurological disease/ Cancer/.

3 Thyroid gland disease/ Diabetes/ Other/ ( ). How old were you when you became ill?/ . Age: (years old)/ . Do you smoke?/ . Yes/ Current amount/ : cigarettes/day/ / Duration/ : years/ . No, but I used Previous amount/ : cigarettes/day/ / Duration/ : years/ . No/ . Do you drink alcohol?/ . Yes/ mL/day/ ml/ No/ . Have you ever had any surgery?/ . Yes/ No/ . When was the surgery?/ . Approximately: year/ month/ (type of surgery/ : ). Have you ever had any anesthesia?/ . Yes/ General anesthesia/ Local anesthesia/ . No/ . Did you have any problems related to the anesthesia?/ . Yes/ No/ . Have you ever had a blood transfusion?/ . Yes/ No/ . Did you have any problems related to a blood transfusion?/ . Yes/ No/ . Is there a possibility that you are pregnant?/ . Yes/ months pregnant/ I do not know/ No/ . Are you breastfeeding?/ . Yes/ No/.

4 Will you be able to bring an interpreter with you in the future?/ . Yes/ No/ . 2/2. 2014.