Questionnaire Word version
MEDICAL QUESTIONNAIRE
Please, save as a Word document and adjust the amount of blank space you may need for each question.
CONFIDENTIAL:
DATE __________________________________
NAME: ___________________________________________________
ADDRESS: ______________________________________________________________
__________________________________.Tel. No________________.
e-mail address:____________________________________
D.O.B: ??/??/?? Male/Female HEIGHT: ???... WEIGHT: ???..
PAST MEDICAL HISTORY: Have you had any serious medical condition in the past such as glandular fever or cancer, any major operations, or any eating disorders such as anorexia, etc? If so, then please tells me the dates. If you have travelled abroad ? please, say where and when? Did you have any illnesses like food poisoning when abroad or on return?
HISTORY OF PRESENT CONDITION: How did the illness begin?- in other words did it begin suddenly or gradually? what were the first symptoms? did they change over a period of time? what made things better or worse? what diagnoses were made and investigations undertaken and treatment given?
CURRENT MAIN SYMPTOMS - for each symptom: when did it begin, how bad is it, is the symptom constant or intermittent, what makes it fluctuate, what else is affected such as sleep, concentration etc, what are the provoking and relieving factors
FAMILY HISTORY: Are your parents and/or grandparents are alive; if not, what did they die from and at what age? Do you have any brothers or sisters or children - are they fit and well?. Are there any illnesses such as cancer, heart disease or diabetes which run in the family.
PRESENT MEDICATION: Are you on any tablets prescribed by your GP, or do you take any herbal or homoeopathic medication, or vitamin or mineral supplements
OCCUPATION: Many illnesses are caused by exposures to chemicals or allergens. Details of jobs give me some idea as to what you may have been exposed. For example, farmers are exposed to pesticides, miners to dusts, factory workers to chemicals and dusts.
TESTS AND INVESTIGATIONS WHICH HAVE ALREADY BEEN DONE - There is no point in repeating tests which have been done recently. I need to know the results of previous tests alongside the normal ranges for the laboratory which has done those tests and when they were done
DIET: e.g. vegetarian, vegan, addict (to sugar, alcohol, caffeine, other? ? be honest)
ALLERGIES: Do you react allergically to any foods, inhalants or chemicals (including drugs)
SLEEP: What time do you go to bed, how long does it take you to drop off to sleep? Is your sleep peaceful and refreshing or is it disturbed? When do you wake up? When do you rise?
YOUR GP'S NAME, ADDRESS and E-MAIL ADDRESS if available
