Medical history questionnaire

Please enter the identification code from your SMS/email

Please enter the identification code from your SMS/email* This field is required.

Do you have any cardiovascular disease?* This field is required.

Hypertension/High blood pressure

Dyslipidaemia/ High cholesterol

Ischaemic heart disease/Angina/Heart Attacks

Heart Failure/Cardiomyopathy

Heart arrhythmias/Atrial Fibrilation/Pacemaker

Peripheral vascular disease

Do you have a cardiologist (heart specialist)?* This field is required.

YESNO

Name of cardiologist* This field is required.

Do you have and Respiratory/Lung disease?* This field is required.

Asthma

COPD/Emphysema

Pulmonary Fibrosis

Bronchiectasis

Obstructive Sleep Apnoea (OSA)

Do you use a CPAP machine?* This field is required.

YESNO

Do you have a respiratory physician (lung specialist)?

YESNO

Name of Respiratory physician* This field is required.

Do you have diabetes?* This field is required.

Yes - Type 1 (childhood onset, on insulin straight away)

Yes - Type 2 - diet controlled

Yes - Type 2 - on tablets only

Yes - Type 2 - on insulin (with or without tablets)

Has your diabetes caused other problems?* This field is required.

Peripheral neuropathy (numbness/pain in feet +/- hands)

Nephropathy/ Kidney Problems

Retinopathy/ eye problems

Do you have an endocrinologist (diabetes specialist)?* This field is required.

YESNO

Name of endocrinologist* This field is required.

Do you have any problems with your thyroid?* This field is required.

Hypothyroid (need thyroxine replacement)

Hyperthyroid (need suppression of thyroxine)

Do you have any gastrointestinal problems?* This field is required.

GORD/reflux/stomach ulcers

Chronic Pancreatitis

Irritable bowel disease (IBS)

Coeliac Disease

Inflammatory bowel disease (IBD)

What type of inflammatory bowel disease?* This field is required.

Crohn's Disease

Ulcerative Colitis

Other

Do you have any problems with your liver?* This field is required.

YESNO

What type of problem?* This field is required.

Fatty Liver

Cirrhosis

Primary Sclerosing Cholangitis

Primary Billiary Sclerosis

I'm not sure

Other

Do you have a gastroenterologist (GI/Liver Specialist)?* This field is required.

YESNO

Name of gastroenterologist* This field is required.

Do you have any problems with your kidneys?* This field is required.

YESNO

What problems?* This field is required.

Impaired renal function/faliure

Glomerulonephrosis/nephritis

Polycytic kidney disease

Renal stones

Other

Do you have a nephrologist (kidney specialist)?* This field is required.

YESNO

Name of nephrologist?* This field is required.

Are you on dialysis?* This field is required.

Haemodialysis

Peritoneal dialysis

Have you ever had a kidney transplant?* This field is required.

YESNO

Do you have any neurological disorders?* This field is required.

Epilepsy/Seizures

Stroke/TIAs

Multiple Sclerosis

Parkinson's Disease

Peripheral neuropathy

Migraines

Other headaches

Other

Does your peripheral neuropathy have a known cause?* This field is required.ie Diabetes, Chemotherapy, CIDP, other medications, alcohol, thyroid, amyloidosis, hereditory

YESNO

Cause of peripheral neuropathy?* This field is required.

Type of headache* This field is required.

Do you have a neurologist (brain/nervous system specialist)?* This field is required.

YESNO

Name of neurologist* This field is required.

Do you have any mental health conditions?* This field is required.

Depression

Anxiety

Post Traumatic Stress Disorder (PTSD)

Bipolar affective disorder

Personality Disorder

Schizophrenia/Psychotic disorder

Other

Type of personality disorder* This field is required.Borderline PD, EUPD, Obsessive Compulsive PD, Histrionic PD, Narcissistic PD, Avoidant PD, Dependent PD

Do you have a clinical psychologist?* This field is required.

Yes - I still see regularly

Previously, but no longer seeing

Name of clinical psychologist?* This field is required.

Do you have a psychiatrist (mental health specialist doctor)?* This field is required.

Yes - I still see

Previously, but I no longer see

Name of psychiatrist* This field is required.

Do you have a history of cancer?* This field is required.

YESNO

Type/s of cancer?

What year were you diagnosed with cancer?

Are you still receiving cancer therapy?

YESNO

What treatments have you received for your cancer?

Surgery

Chemotherapy

Radiotherapy

Other

Do you have an oncologist (cancer specialist)?

YESNO

Name of oncologist

Do you have musculoskeletal problems?* This field is required.

Osteoarthritis (OA)

Inflammatory arthritis

Spondylosis (arthritis of spine)

Fibromyalgia

Connective tissue disorder

Polymyalgia Rheumatica

Osteoporosis

Gout

Other

Type of inflammatory arthritis? * This field is required.eg, Rheumatoid arthritis, Ankylosing Spondylitis, Psoriatic arthritis, SLE, juvenile idiopathic arthritis

Type of connective tissue disorder* This field is required.eg. Ehlers-Danlos, Marfan's, SLE, Scleroderma, Mixed connective tissue disease, polymyositis, dermatomyositis

Do you have a Rheumatologist?* This field is required.

YESNO

Name of Rheumatologist* This field is required.

Have you previously had joint replacement surgery?* This field is required.

YESNO

Type of joint replacement?* This field is required.

Total knee replacement

Total hip replacement

Total shoulder replacement

Other

Have you had other orthopaedic surgery?* This field is required.

YESNO

Type of surgery* This field is required.

Knee arthroscopy

ACL or other knee ligament repair

Hip arthroscopy

Shoulder arthroscopy

Rotator cuff repair

Foot/ankle arthroscopy/surgery

Other

Name of Orthopaedic Surgeon/s?* This field is required.

Have you ever had surgery on your spine?* This field is required.

YESNO

Which parts of your spine?* This field is required.

Cervical (neck)

Thoracic (chest)

Lumbar/Sacral (lower back)

What surgery have you had on your cervical spine (neck)?* This field is required.

Anterior fusion (ACDF) (from front)

Posterior fusion (from back of neck)

Laminectomy

Foraminal decompression

I'm not sure

Other

What surgery have you had on your thoracic spine?* This field is required.

Fusion

Laminectomy

I'm not sure

Other

What surgery have you had on your lumbar/sacral spine (lower back)?* This field is required.

Microdiscectomy

Laminectomy (decompression)

Anterior fusion (through tummy)

Posterior/Posterolateral fusion (through back)

Artificial disc replacement

I'm not sure

Other

Do you have any auto-immune or other immunological diseases?* This field is required.

YESNO

Please list* This field is required.

Do you have an immunologist?* This field is required.

YESNO

Name of immunologist?* This field is required.

Have you ever had any bleeding or blood clotting disorders?* This field is required.

YESNO

Please list* This field is required.

Do you have a haematologist?* This field is required.

YESNO

Name of haematologist?* This field is required.

Do you currently take any medications (including non-prescription and herbal)?* This field is required.

YESNO

Please input you medications one by one until you have listed them all

Medications (including non-prescription and herbal medications)If on more than one medication please list one

Name of medication

Dose of medication

Units (g/mg/mcg/tablets)

Frequency

At what time of day do you take {medication1[1]} ?

Morning (mane)

Midday

Evening (nocte)

On average how many times per week do you take {medication1[1]}?* This field is required.

Do you take any other medications?

YESNO

Medications (including non-prescription and herbal medications)If one multiple other medications please pick another

Name of medication

Dose of medication

Units (g/mg/mcg/tablets)

Frequency

At what time of day do you take {medication2[1]} ?

Morning (mane)

Midday

Evening (nocte)

On average how many times per week do you take {medication2[1]}?* This field is required.

Do you take any other medications?

YESNO

Medications (including non-prescription and herbal medications)If one multiple other medications please pick another

Name of medication

Dose of medication

Units (g/mg/mcg/tablets)

Frequency

At what time of day do you take {medication3[1]} ?

Morning (mane)

Midday

Evening (nocte)

On average how many times per week do you take {medication3[1]}?* This field is required.

Do you take any other medications?

YESNO

Medications (including non-prescription and herbal medications)If one multiple other medications please pick another

Name of medication

Dose of medication

Units (g/mg/mcg/tablets)

Frequency

At what time of day do you take {medication4[1]} ?

Morning (mane)

Midday

Evening (nocte)

On average how many times per week do you take {medication4[1]}?* This field is required.

Do you take any other medications?

YESNO

Medications (including non-prescription and herbal medications)If one multiple other medications please pick another

Name of medication

Dose of medication

Units (g/mg/mcg/tablets)

Frequency

At what time of day do you take {medication5[1]} ?

Morning (mane)

Midday

Evening (nocte)

On average how many times per week do you take {medication5[1]}?* This field is required.

Do you take any other medications?

YESNO

Medications (including non-prescription and herbal medications)If one multiple other medications please pick another

Name of medication

Dose of medication

Units (g/mg/mcg/tablets)

Frequency

At what time of day do you take {medication6[1]} ?

Morning (mane)

Midday

Evening (nocte)

On average how many times per week do you take {medication6[1]}?* This field is required.

Do you take any other medications?

YESNO

Medications (including non-prescription and herbal medications)If one multiple other medications please pick another

Name of medication

Dose of medication

Units (g/mg/mcg/tablets)

Frequency

At what time of day do you take {medication7[1]} ?

Morning (mane)

Midday

Evening (nocte)

On average how many times per week do you take {medication7[1]}?* This field is required.

Do you take any other medications?

YESNO

Medications (including non-prescription and herbal medications)If one multiple other medications please pick another

Name of medication

Dose of medication

Units (g/mg/mcg/tablets)

Frequency

100

At what time of day do you take {medication8[1]} ?

Morning (mane)

Midday

Evening (nocte)

101

On average how many times per week do you take {medication8[1]}?* This field is required.

102

Do you take any other medications?

YESNO

103

Medications (including non-prescription and herbal medications)If one multiple other medications please pick another

Name of medication

Dose of medication

Units (g/mg/mcg/tablets)

Frequency

104

At what time of day do you take {medication9[1]} ?

Morning (mane)

Midday

Evening (nocte)

105

On average how many times per week do you take {medication9[1]}?* This field is required.

106

Do you take any other medications?

YESNO

107

Medications (including non-prescription and herbal medications)If one multiple other medications please pick another

Name of medication

Dose of medication

Units (g/mg/mcg/tablets)

Frequency

108

At what time of day do you take {medication10[1]} ?

Morning (mane)

Midday

Evening (nocte)

109

On average how many times per week do you take {medication10[1]}?* This field is required.

110

That's probably enough for now. We can list any other medications at your appointment.

111

Are you allergic to any medications?* This field is required.

YESNO

112

Please list medication allergies* This field is required.

113

Do you smoke?* This field is required.

Yes

No, but I used to

I never smoked

114

On average how many cigarettes do you smoke per day?* This field is required.

115

How long ago did you quit?* This field is required.

116

Do you drink alcohol?* This field is required.

YESNO

117

On average how many drinks per week?* This field is required.

118

How tall are you (approximately)?* This field is required.

cm/feet and inches

119

How much do you weigh (approximately)?* This field is required.

kg/lbs/stone