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    Your Full Name

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    Vagamundos Argentinos
    This document is a health questionnaire that collects personal health information from an individual. It requests information such as name, height, weight, smoking status, pregnancy status, overseas travel history, allergies, current medications, past medical history including conditions like high blood pressure, heart attack, asthma, cancer, diabetes and more. It also asks about hospital admissions and surgeries. The extensive form aims to gather a comprehensive medical history from the person.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Your Full Name

    Uploaded by

    Vagamundos Argentinos
    27 views2 pages
    This document is a health questionnaire that collects personal health information from an individual. It requests information such as name, height, weight, smoking status, pregnancy status, overseas travel history, allergies, current medications, past medical history including conditions like high blood pressure, heart attack, asthma, cancer, diabetes and more. It also asks about hospital admissions and surgeries. The extensive form aims to gather a comprehensive medical history from the person.

    Original Title

    Health Questionnaire_template

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    This document is a health questionnaire that collects personal health information from an individual. It requests information such as name, height, weight, smoking status, pregnancy status, overseas travel history, allergies, current medications, past medical history including conditions like high blood pressure, heart attack, asthma, cancer, diabetes and more. It also asks about hospital admissions and surgeries. The extensive form aims to gather a comprehensive medical history from the person.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    27 views2 pages

    Your Full Name

    Uploaded by

    Vagamundos Argentinos
    This document is a health questionnaire that collects personal health information from an individual. It requests information such as name, height, weight, smoking status, pregnancy status, overseas travel history, allergies, current medications, past medical history including conditions like high blood pressure, heart attack, asthma, cancer, diabetes and more. It also asks about hospital admissions and surgeries. The extensive form aims to gather a comprehensive medical history from the person.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    HEALTH QUESTIONNAIRE

    Your Full Name: ____________________________________________________

    YOUR HEIGHT _______ METRES

    YOUR WEIGHT _______ KG


    DO YOU SMOKE? YES NO QUIT
    ______ / Day Quit Date

    PREGNANT/POSSIBLY PREGNANT? YES NO

    HAVE YOU REURNED FROM OVERSEAS


    WITHIN THE LAST 2 WEEKS (14 DAYS) YES NO
    _______________________
    IF YES, PLEASE SPECIFY COUNTRIES VISITED: ___

    ALLERGIES (ARE YOU ALLERGIC TO ANY


    MEDICINES / FOODS THAT YOU KNOW
    ABOUT?) YES NO
    IF YES, PLEASE SPECIFY:

    CURRENT MEDICINES (PLEASE LIST ALL


    MEDICINES-TABLETS, INHALERS, PATCHES
    ETC PRESCRIBED BY A DOCTOR OR OVER THE
    COUNTER)

    PAST MEDICAL & SURGICAL HISTORY


    DO YOU HAVE, OR HAVE YOU EVER HAD,
    ANY OF TH FOLLOWING?
    HIGH BLOOD PRESSURE YES NO
    HEART ATTACK YES NO
    HEART MURMURS YES NO
    ARTIFICAL HEART VALVE YES NO
    CHEST PAINS/ANGINA YES NO
    RHEUMATIC FEVER YES NO
    IRREGULAR HEART RHYTHM YES NO
    ASTHMA YES NO
    EMPHYSEMA/BRONCHITIS YES NO
    CORD (Chronic Obstructive Respiratory
    Disease) YES NO
    SHORTNESS OF BREATH YES NO
    SLEEP APNOEA YES NO
    STROKE/CVA/TIA YES NO
    ANAEMIA/BLEEDING DISORDER YES NO
    BLOOD CLOTS YES NO
    JOINT IMPLANTS/REPLACEMENTS YES NO
    HIV/AIDS YES NO
    BIRTH ABNORMALITY YES NO
    CANCER YES NO
    Page 1 of 2
    HEALTH QUESTIONNAIRE
    DIABETES YES NO
    EPILEPSY/SEIZURE YES NO
    GOUT YES NO
    HIGH BLOOD PRESSURE YES NO
    REFLUX/HEARTBURN YES NO
    HEPATITIS/LIVER YES NO
    KIDNEY DISEASE YES NO
    VISUAL IMPAIRMENT YES NO
    HEARING DIFFICULTIES YES NO
    MENTAL HEALTH CONDITION YES NO
    DEPRESSION YES NO
    THYROID DISEASE YES NO
    TB/TUBERCULOSIS YES NO
    ARTHRITIS YES NO
    ANXIETY/PHOBIA YES NO
    PARKINSON'S YES NO
    ALZHEIMER'S/DEMENTIA YES NO

    ANY OTHER HEALTH CONDITIONS THAT


    YOU FEEL WE SHOULD KNOW ABOUT? YES NO
    IF YES, PLEASE SPECIFY:

    HOSPITAL ADMISSIONS YES NO


    PLEASE LIST ALL OPERATIONS OR REASON
    FOR ADMISSION TO HOSPITAL

    Page 2 of 2

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