EHC Prescreening Medical Questionnaire

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Pre Screening Form

    First Name
    Last Name
    Sex
    MaleFemale
    Profession
    Industry
    Skype ID
    Telephone +(xxx)(phone)
    Email
    Address
    Text Label
    Text Label
    Text Label
    Text Label

    Family Medical History

    Is there any known "Medical Conditions" in your family?
    YesNo
    If yes, Please indicate.

    Family History

    Hypertension (High blood pressure)
    Grand Parents
    YesNo
    Mother
    YesNo
    Father
    YesNo
    Sister(s)/ Brothers(s)
    YesNo
    Diabetes
    Grand Parents
    YesNo
    Mother
    YesNo
    Father
    YesNo
    Sister(s)/ Brothers(s)
    YesNo
    Heart Disease or Heart Attack
    Grand Parents
    YesNo
    Mother
    YesNo
    Father
    YesNo
    Sister(s)/ Brothers(s)
    YesNo
    Stroke (Cerebro-Vascular Accident)
    Grand Parents
    YesNo
    Mother
    YesNo
    Father
    YesNo
    Sister(s)/ Brothers(s)
    YesNo
    Cancer (of any type)
    Grand Parents
    YesNo
    Cancer Type
    Mother
    YesNo
    Cancer Type
    Father
    YesNo
    Cancer Type
    Sister(s)/ Brothers(s)
    YesNo
    Cancer Type
    Other significant conditions)
    Other Conditions
    Other Conditions
    Other Conditions
    Other Conditions

    Personal Medical Background

    Current Weight
    Text Label
    KilogramsPounds
    Current Height
    Text Label
    MetersFeet

    Personal Activity

    Do you have no or Limited Activity?
    YesNo
    Times Per Week
    Type of Activity

    Alcohol Consumption

    Do you drink Alcohol?
    YesNo
    On exceptional basis?
    YesNo
    On a regular basis
    YesNo

    Tobacco Consumption

    Tobacco Use
    Did not smoke but exposed to high smoking environment for a long period of years
    YesNo
    Currently Smoke?
    YesNo
    Please details the average past and current tobacco consumption
    Past Consumption
    Cigarettes / day
    Cigars/ day
    How many years
    Current Consumption
    Cigarettes / day
    Cigars / day
    Number of years

    Stress Levels

    "Burnout Syndrome" (Executive Overstress condition)
    YesNo
    If yes, mention the date (year)
    Personal Stress Assessment (Average daily))
    YesNo
    Please rate your stress level on a 0 to 10 scale. 10= Extremely high stress level

    Medical Background

    Do you have an allergy to food or environmental factors?
    YesNo
    If yes, what type(s)
    Do you have an allergy to medicine
    YesNo
    If yes, what type(s)

    Past Medical Conditions

    Do you have any of the following conditions?
    Hypertension
    YesNo
    if you know your blood pressure, Please Provide:
    Diabetes
    YesNo
    if you know your fasting blood glucose, Please Provide:
    High Cholesterol
    YesNo
    if you know your blood cholesterol, Please Provide:
    Have you contracted any serious conditions in the past?
    YesNo
    If yes, which ones, and when?
    Have you undergone surgery in the past?
    YesNo
    If yes, for what reason and when?
    Do you take nutrients / vitamins on a regular basis??
    YesNo
    If yes, Which ones?

    Current Medical Conditions

    Text Label
    YesNo
    If yes, which condition?
    Please indicate your current treatment?

    Current Symptoms

    Do you have any medical complaint(s) bothering you?
    YesNo
    If yes, please describe which ones and for how long
    Have you experienced unusual excessive tiredness?
    YesNo
    If yes, please assess your current fatigue level on 0 to 10 scale
    Weight (Past 4 months): is your body weight stable?
    YesNo
    If no, mention weight loss or gain in kg
    Appetite(past 4 months) is your appetite stable?)
    YesNo
    If no, assess your current appetite on a scale of 0 to 10
    Please assess your current energy level on 0 to 10 scale
    Please assess your overall sleep quality on 0 to 10 scale

    Current Symptoms

    Pain of unknown origin
    YesNo
    Shortness of breath
    YesNo
    Difficulty Walking
    YesNo
    Difficulty in Strenuous Activities
    YesNo
    Blood in stool, sputum, urine
    YesNo
    Difficulites Urinating
    YesNo
    Skin lesions of any type
    YesNo
    Difficulties in digesting
    YesNo
    Difficulties in bowel movement
    YesNo
    Hearing loss or pain in ears
    YesNo
    Vision problems, pain, blurred vision
    YesNo
    Dizziness or Vertigo
    YesNo
    Marks on the skin which have changed
    YesNo
    Itching or skin lack of sensitivity
    YesNo

    Information related to Obstetrics and Gynecology (FOR WOMEN ONLY)

    Number of deliveries
    First day of Last menstruations
    Date of last pap smear
    Please mention results or bring copy of report
    Have you had gynecology problems in the past
    YesNo
    If yes,please describe and how long?
    Do you have any bleeding between menstruations
    YesNo
    If yes, please describe

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