Share  Facebook  Twitter
PRIEST IS CURRENTLY OFFERING DISCOUNT TO COMPANIES, GOVERNMENTS AND FAMILIES. PLEASE CONTACT US TO DISCUSS YOUR NEEDS.
Skip Navigation LinksHome  >  Services  >  Emegency Transfer   >  Medical History questionaire

MEDICAL HISTORY QUESTIONAIRE

All the information that you provide in this questionaire is strictly confidential and will become part of your medical record. Click on each tab to answer the questions contained. All questions are to be answered.

Patient Information

Surname
Other name(s)
Date of Birth (dd/mm/yyyy)
Gender
Female          Male
Marital Status
Single          Married          Seperated          Widowed          Other
Name of previous or referring doctor:

Contact Details

Nationality:
Language(s) Spoken
*more than one? Seperate with comma
Contact Address
Telephone Number(s)
*more than one? Seperate with comma
Mobile Number(s)
*more than one? Seperate with comma
Fax Number(s)
*more than one? Seperate with comma
Email Address

Personal Health History

Current Medical History
Diagnosis
Symptoms
Treatment
Complications
Have you ever had a blood transfusion?
Yes          No
Date of Transfusions (dd/mm/yyyy)
more than one? Seperate with comma
List any medical problems that other doctors have diagnosed
*more than one? Seperate with comma

Investigations

***Please indicate if you have had any of the following tests and state the date(s) of the test.

Investigation Tick box if you have had the investigation Date (dd/mm/yyyy)
Full blood count/PCV
Urea and electrolytes/creatinine
Liver function tests
Thyroid function tests
Prostatic Specific Antigen (PSA)
Urinalysis
Fasting/Random blood sugar
Chest X ray
Ultrasound Scan
CT Scan/ MRI
ECG
Echocardiogram
Exercise Tolerance Test
Please state any other investigations you may have had, not stated above

Childhood Illness

***Please indicate if you have had any of these illnesses in the past

Illness Tick box if you have had the illness
Mumps
Measles
Rubella
Chicken pox
Typhoid fever
Malaria fever
Other

Immunizations and Dates

***Please indicate if you have received immunizations against any of these infections.

Infection Tick box if you have had the immunization Date (dd/mm/yyyy)
Tetanus
Hepatitis
Influenza
Pneumonia
Chicken Pox
MMR
Other

Previous Surgeries

***Please list any surgeries that you have had

Surgical Operations Date (dd/mm/yyyy)

Hospitalisations

***Please indicate if you have been hospitalised.

Hospital Reason Date (dd/mm/yyyy)

Medication

***List all medicines that you are currently taking (including prescribed drugs, over-the- counter drugs, vitamins, inhalers, herbal medication etc).

Medication Dose Frequency Date Started (dd/mm/yyyy)

Medical Allergies

***List any medications that you are allergic to and the reaction that you had from taking the medications.

Medication Type of Reaction Date of Reaction (dd/mm/yyyy)

Health Habits and Personal Safety

Exercise

***Please indicate your level of exercise as described below

Exercise Select one option
Sedentary (no exercise)
Mild exercise (climb stairs, frequent walk, golf)
Occasional vigorous exercise (less than 4 times per week for 30 min.)
Regular vigorous exercise (more than 4 times per week for 30 min.)

Diet

Diet Select one option
Are you currently dieting?(tick as appropriate) Yes          No
Is it a doctor prescribed medical diet? Yes          No
Rank your salt intake High          Medium          Low
Rank your fat intake High          Medium          Low

Caffeine Intake

Caffeine Sources Select the appropriate option If yes, ,  indicate how many cups/number per day
Cola Drinks         Yes          No
Tea         Yes          No
Coffee        Yes          No
Kolanut         Yes          No

Tobacco

Tobacco Indicate appropriately
Do you use tobacco? Currently          Previously          Never
If you are currently smoking, how many packs per day
If you have stopped, what date did you stop? (dd/mm/yyyy)

Alchohol

Alchohol Indicate appropriately
Do you drink alcohol? Yes          No
If yes, how many drinks per week?
Are you concerned about the amount you drink? Yes          No
Have you ever considered stopping? Yes         No
Are you prone to binge drinking? Yes          No

Family Health History

Does any close family member suffer from any significant health problem? if yes, please give details below

Family Member Health Problem

Others information

***Any other information, please state.

 





  Privacy Policy • Terms of Condition • Resources • Partners & Affiliates
©Copyright 2010 PRIEST MEDICAL SERVICES LIMITED. All rights reserved