Patient questionnaire
Patient questionnaire
Patient information:
First name
Last name
Date of birth
Street address
City, Zip code
Insured: privately publicly
Contact details:
Telephone*
Fascimile
Mobile telephone
Email*
General information:
Height
Weight
Occupation
How would you describe your current health?
Very good
Good
Not good
Poor
Do you have high blood pressure?
Yes, last reading:
No
I don?t? know
When was your last complete physical exam (blood work, EKG, chest x-ray, ultrasound, etc.)?
Date
Do you know your blood count?
Yes
No
Blood sugar
Cholesterol
Other
Have you been diagnosed with an illness?
Yes No
If yes, which one?
If yes, what treatment have you begun?
Are you currently being medically treated? Yes No
Does your family have a history of medical illness or disease?
Yes
No
If yes, what?
If yes, which family member?
Have there been instances of serious illness or disease in your family (e.g. Parkinson?s disease, Alzheimer?s, rheumatism, diabetes, stroke, heart attack, etc)?
Yes No
If yes, what?
If yes, which family member?
Are you currently taking prescription medication?
Do you suffer from digestive problems?
Yes No
If yes, please describe.
Do you have difficulty urinating?
Yes No
If yes, please describe.
Smoking habit:
I do not smoke
I used to smoke
Yes, I smoke cigarettes / cigarillos daily.
Yes, I smoke occasionally.
Fluid intake:
Non alcoholic:
I drink ____________ liters of water/juice daily
Alcohol:
I consume: ____________ bottles of beer daily
____________ glasses of wine daily
____________ servings of hard liquor daily
I consume alcohol occasionally
I do not drink alcoholic beverages.
Physical activity: I undertake a regular sports regimen
Yes No
If yes, which sport and how often?
Current medical concern / symptoms:
Using your mouse, please click on the area where you are experiencing pain.
Your current symptom could best be described as:
Pain
Limited/reduced mobility
Anxiety / concern
Sensitive (numbness, tingling, pins and needles)
Other
Please describe your symptoms (pulling, sharp or stabbing, spasms, etc.).
How long have you been experiencing these symptoms?
You experience the symptoms:
Occasionally
Continually
When you perform an activity, for example, _____________
Are your symptoms due to an accident / trauma?
Have you previously had an operation or surgery?
Yes No
If yes, where were you operated on and when was the operation?
Other comments / concerns:
To prevent the misuse and submission of spam, please enter the letters or numbers appearing in the box below. Only by entering the below information correctly will we receive your patient information. ________________
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Your information will be stored in our system solely for the purposes of assessing your medical needs and will be handled pursuant to all legal data privacy regulations. We will not share or give your information to any third-party in any form.