MEDICAL QUESTIONNAIRE Fill in correctly the details below Please enable JavaScript in your browser to complete this form.Full Name *FirstLastIDEmail *Medical AID:YesNoNO:Number of Dependants:Next of Kin:Relationship:Phone Number:Medical Concerns:Medical History:Symptoms:Medication And Vitamins (Current Treatment)State out your current medications and vitaminsMedication And Vitamins (Previous Treatment)State out your previous medications and vitaminsSURGICAL HISTORY:state out your previous surgical history ALLERGIES:state out your allergies FATHER'S MEDICAL HISTORYMOTHER'S MEDICAL HISTORYSIBLINGS MEDICAL HISTORYMenarche:Last period:Cycle:Breast tenderness:Hot flushes:Number of Pregnancies:Cyst on Ovary:Endimetriosis:Uterine fibroids:Menopause:PMS:Bleed, heavy or normal?Fibrocystic breast:Night sweats:Vaginal dryness:Miscarriages:PCOS HPV Virus:Last PSA: Well‐being: Muscle loss: Well‐being:Muscle loss:Decreased Libido:Erectile dystuncyion:Prostatitis:Weight:Height:Eating PatternMorningAfternoonLunchEveningAfter 11pmStress level (scale of 1 - 10) Selected Value: 0 Use the slider to indicate stress levelSleep pattern:Depression ?YesNoMood Swing?YesNoAnxiety?YesNoAggression?YesNoIrritability?YesNoMotivation?YesNoAlcohol?YesNoRecreational Drugs?YesNoSmoking?YesNoExercise?YesNoDiet?YesNoToxic exposure?YesNoMammogramPap smear:Bone density:Prostate Examination:Sonar: Gastroscopy:Colonoscopy:Others:Submit
