Medical Questionnaire

Name

Date Of Birth

SexMaleFemale

Weight (kg)

Height (cm)

Date

General Medical History

Please list the main reason or complaint that led you to take this medical consultation

Please briefly state your health conditions, past & current medical history, surgical operation, treatments.

Please list ALL your medications including daily dosages.

Please list ALL vitamin, supplements and natural medications that you are taking:

Do you smoke?

Do you drink alcohol regularly?

Social History:

Are you marriedYesNo

Do you have kids?

What is your occupation?

Average hours of work per day?

Do you exercise regularly?

What is your Diet consist of mostly?

Average hours of sleep per night?

Family Medical History:

Please indicate any member of your family (grandparents, parents, brothers, sisters, aunts and uncles, your children) who suffers from the following.

Overweight
Underweight
Depression
Epilepsy
Migraine
Eczema
Psoriasis
Acne
Lung emphysema
Chronic bronchitis
Asthma
Lung tuberculosis

Allergies
Goiter
High blood pressure
Low blood pressure
Rheumatism
Gout
Heart attack
Legs arteriosclerosis
Stomach ulcer
Gallstones
Kidney stones
Juvenile diabetes (Type 1)

Maturity onset diabetes (Type 2)
Precocious puberty (Before age 12)
Late puberty (After age 15)
Breast cancer
Prostate cancer
Osteoporosis
Osteoarthritis
Parkinson’s disease
Alzheimer’s disease

If yes, please indicate his or her relationship to you.

Section 1

Please answer the following questions truthfully using the following numbers: 0=not at all; 1=rarely; 2=often; 3=most of the time

Do you experience or feel…

43. Intolerance to cold0123

Section 2

Section 3

43. Poor thirst (poor drinking)0123

Section 4 Section 5 (For Men Only)

16. Sex performance as follows:

a) Decreased frequency of intercourseyesNo

b) Decreased frequency of erectionsyesNo

Section 5 (For Women Only)

When was your first menstruation?

When was your last menstruation? (if applicable)

If you still menstruating:

Is it light or heavy?

Is it punctual?

Is it painful?

Do you feel mood swings, depressed or aggressive around that time?

Do you experience, suffer or feel:

18. Fat excess in the following parts:

a) BreastsyesNo

b) HipsyesNo

c) BellyyesNo

d) ButtocksyesNo

19. Varicose veinsyesNo

How many children do you have?

How many pregnancies have you ever had?

How many miscarriages?

Caesarean section (C-section) at delivery? if yes, why?

Do you have an intra-uterine device (IUD)? if yes, which type (with or without hormones)?