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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