Your Health Assessment Questionnaire

YOUR HEALTH ASSESSMENT QUESTIONNAIRE
Your personal details
Title
(Mr, Mrs, Miss, Ms, other title)
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Age
Previous Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home telephone Number
Work telephone Number
Mobile telephone Number
Email
example@example.com
Are you covered by private medical insurance?

Yes No
Details
Date questionnaire completed

Month Day Year
Date
Please complete the following if your employer is paying for this assessment:
Company Name
Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
KEEPING YOUR GP INFORMED AND MONITORING FURTHER ACTION

It is good practice for your GP to be kept informed of all aspects relating to your health. Please complete the information bellow if you are happy for us to send your GP an abbreviated version of your report and advise him or her of any abnormalities or significant results that may require follow-up investigation or treatment.
GP Name
GP address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
GP telephone number
BHC monitors what happens to customers after certain screening tests and certain abnormal results. This allows us to check on the quality of these tests and ensure that any necessary action has taken place. Please indicate whether or not you are happy for us to contact the following:
You

Yes No
Your GP

Yes No
Please Sign

Clear
Date filled

Month Day Year
Date
PLEASE TELL US YOUR MAIN REASONS FOR ATTENDING
Review of health Medical problem Company requirement Other reason
If you have any specific areas of concern, please list them in priority order
1. Primary concern
2. Secondary concern
Your assessment includes a large number of tests covering a wide range of medical conditions. As with most medical tests and services, it is not always possible to detect all diseases and abnormalities. You should be aware that this assessment is aimed at offering advice and insight into your lifestyle and offering adaptions where required to enable you to seek better health and well being. If however, any medical symptoms you have do not resolve as expected or any new symptoms arise, you should seek further medical advice.
PLEASE TELL US ABOUT YOURSELF AND YOUR FAMILY

Material status
Are you:

Single Married Divorced Separated Widowed Cohabiting Other
If married, how long have you been married?
Years
Spouse age
Spouse occupation
Spouse's health

Good Fair Poor
Number of Children : Sons
Number of Children : Daughters
HAVE ANY NEAR RELATIVES EVER HAD ANY SERIOUS HEALTH PROBLEMS? IF SO, PLEASE OUTLINE BRIEFLY BELOW
YOUR JOB HISTORY

If you are in employment please answer the following questions:
How many hours a week on average do you work?
hours
How many hours a week on average do you work at home?
hours
Do you take your full holiday allowance?

Yes Mostly No
How many days off work due to sickness have you had in the past two years?
Days
YOUR LIFESTYLE

Your exercise and activity
How much aerobic exercise do you take? (By aerobic exercise we mean continuous bodily activity sufficient to increase your breathing rate moderately)

Less than once a week 1-2 times a week 3 times a week 4 or more times a week
Are you a member of a gym?

Yes No
Are you generally active as part of your daily routine? eg. do you walk a lot, do you use the stairs instead of the lift, are you a keen gardener?

Yes No
Your Diet
Do you limit the amount of refined sugar in your diet? eg sugar, sweets, biscuits, chocolate, cakes

Yes No
Do you eat foods high in fibre on a daily basis? eg wholemeal bread, pulses and lentils, high fibre breakfast cereals,and generally unrefined wholemeal foods such as brown rice and brown pasta.

Yes No
Do you limit your intake of saturated fat? eg butter, cream, cakes, eggs and fatty meats

Yes No
Do you eat five or more portions of fruit and/or vegetables each day?

Yes No
Do you eat more fish and poultry than red meat?

Yes No
Do you drink about 2 to 2.5 litres of fluid a day? (this includes fluids contained within food) Most people with a moderate activity level and in a moderate temperature have about 2 to 2.5 litres of fluid a day (about seven to eight medium-sized glasses).

Yes No
How many cups of caffeinated tea and coffee do you drink a day?

Yes No
Has your weight been steady recently?

Yes No
Smoking
Do you smoke?

Never Given up Yes
If given up, when?
Year
If yes, how many per day? Please specify cigarettes, cigars or pipe
If you are a non-smoker, are you regularly exposed to a smoky atmosphere?

Yes No
Alcohol
How often do you drink alcohol?

Never Weekends only On special occasions Most Days Once or twice a month Every day Once or twice a week
How many units of alcohol do you typically drink over the course of a week? (One unit is equal to 10ml by volume of 8g by weight of pure-alcohol. One unit of alcohol is equal to: one 25ml single measure of spirit (40%ABV); half a standard (117ml) glass of red wine (12% ABV); a third of a pint of strong beer (5% ABV)
Your Medical History

Have you ever had any of the following ? If yes, please give details and dates as appropriate.
Stroke

Yes No
Details
Deep vein thrombosis

Yes No
Details
Kidney problems, stones

Yes No
Details
Cystitis (urine infection)

Yes No
Details
Bronchitis, Emphysema

Yes No
Details
Asthma

Yes No
Details
Tuberculosis

Yes No
Details
Pneumonia, pleurisy

Yes No
Details
Peptic ulcer, indigestion

Yes No
Details
Jaundice, hepatitis

Yes No
Details
Gallstones

Yes No
Details
Piles or fissures

Yes No
Details
Polyps in colon

Yes No
Details
Colitis, irritable bowel

Yes No
Details
Diabetes

Yes No
Details
Thyroid problems

Yes No
Details
Mumps

Yes No
Details
Blood disorder eg anaemia

Yes No
Details
Malaria

Yes No
Details
Other tropical diseases

Yes No
Details
Mental problems

Yes No
Details
Depression

Yes No
Details
Anxiety

Yes No
Details
Fits, epilepsy, blackouts

Yes No
Details
Migraine, recurrent headaches

Yes No
Details
Concussion, head injury

Yes No
Details
Cancer

Yes No
Details
Other glandular disorders

Yes No
Details
Problems with veins, varicose veins

Yes No
Details
Glaucoma

Yes No
Details
Ear disease or discharge

Yes No
Details
Skin problems eg eczema

Yes No
Details
Back problems

Yes No
Details
Arthritis, gout

Yes No
Details
Bone fractures, osteoporosis

Yes No
Details
Muscle or nerve disease

Yes No
Details
Sexually transmitted infections eg chlamydia

Yes No
Details
Prostate or bladder problems

Yes No
Details
Hernia operation

Yes No
Details
Any other operations

Yes No
Details
Accident, injuries

Yes No
Details
Sterilisation, vasectomy

Yes No
Details
Blood transfusion

Yes No
Details
YOUR MEDICAL HISTORY

Have you ever had any condition that has needed treatment from your doctor ?
Your heart, including blood pressure?

Yes No
Your lungs - for instance pneumonia, asthma, bronchitis?

Yes No
Your abdomen - for instance peptic ulcer, hiatus hernia, irritable bowel syndrome?

Yes No
Your kidneys or bladder - for instance kidney stones, urinary infection or cystitis?

Yes No
Also
Have you ever had a fit or fainted?

Yes No
Have you ever had a stroke or "mini-stroke"?

Yes No
Have you ever had or do you have diabetes or any other endocrine (glandular) problems?

Yes No
Have you ever had any periods of anxiety or depression that have interfered with the way you lead your life?

Yes No
Have you ever had any form of cancer?

Yes No
If you are a woman, have you had any breast or gynaecological problems?

Yes No
In the past year, have you suffered from or been unable to work because of the following :

if yes, approximately how many days were you unable to work?
Back pain

Yes No
No. of days not worked
Other muscle or joint pain

Yes No
No. of days not worked
Colds, influenza, virus infection

Yes No
No. of days not worked
Headaches

Yes No
No. of days not worked
Period pain, Pre-menstrual syndrome (PMS)

Yes No
No. of days not worked
Gastric problems (nausea, diarrhoea, vomiting)

Yes No
No. of days not worked
Stress

Yes No
No. of days not worked
Other illnesses

Yes No
No. of days not worked
Injury

Yes No
No. of days not worked
Accidents

Yes No
No. of days not worked
Assault

Yes No
No. of days not worked
Please list any allergies (including allergies to medicines)
Please list any medicines you are taking, either prescribed or bought over the counter
Please give details of any hospital admissions in the past three years
Please give details of any tests or investigations you have had in the past three years
YOUR WELLBEING

Please read this carefully. We would like to now how your health has been in general, over the past few weeks. Please answer ALL the questions by putting a tick in the box indicating the answer which you think most applies to you.
Been able to concentrate on whatever you're doing?

Better then usual Same as usual Worse then usual Much worse then usual
Lost much sleep over worry?

Not at all No more then usual Rather more then usual Much more then usual
Felt you were playing a useful part in things?

More so then usual Same as usual Less so then usual Much less then usual
Felt capable of making decisions about things?

More so then usual Same as usual Less so then usual Much less then usual
Felt constantly under strain?

Not at all No more then usual Rather more then usual Much more then usual
Felt you couldn't over come your difficulties ?

Not at all No more then usual Rather more then usual Much more then usual
Been able to enjoy your normal day-to-day activities ?

More so then usual Same as usual Less so than usual Much less then usual
Been able to face up to your problems?

More so then usual Same as usual Less so than usual Much less then usual
Been feeling unhappy or depressed?

Not at all No more then usual Rather more then usual Much more then usual
Been losing confidence in yourself?

Not at all No more then usual Rather more then usual Much more then usual
Been thinking of yourself as a worthless person ?

Not at all No more then usual Rather more then usual Much more then usual
Been feeling reasonably happy, all things considered?

More so then usual Same as usual Less so then usual Much worse then usual
ABOUT YOUR WORK

If you are in employment, for each question indicate the one answer that best describes your job or the way you deal with problems occurring at work. Please answer ALL the questions.
Do you have to work very fast?

Often Sometimes Seldom Never/almost never
Do you have to work very intensively ?

Often Sometimes Seldom Never/almost never
Do you have enough time to do everything?

Often Sometimes Seldom Never/almost never
Do you have the possibility of learning new thing through your work?

Often Sometimes Seldom Never/almost never
Does your work demand a high level of skill or experience?

Often Sometimes Seldom Never/almost never
Does your job require you to take the initiative?

Often Sometimes Seldom Never/almost never
Do you have to do the same thing over and over again?

Often Sometimes Seldom Never/almost never
Do you have a choice in deciding how you do your work?

Often Sometimes Seldom Never/almost never
Do you have a good deal of say in decisions about work?

Often Sometimes Seldom Never/almost never
Do you find your job satisfying and fullfilling?

Yes No
HEALTH QUESTIONS FOR MEN
Do you regularly examine your testes?

Yes No
Have you ever notices any lumps or swellings in your testes ?

Yes No
Do you get up at night to pass urine on a regular basis?

Yes No
If yes, how many times a night?
Have you noticed any change in the flow rate or stream of your urine?

Yes No
Do you have difficulty in starting and stopping passing urine?

Yes No
Do you have any problems with sexual function?

Yes No
HEALTH QUESTIONS FOR WOMEN
Are your breasts aware and do you know how to examine your breasts?

Yes No
Do you have any problems with your periods?

Yes No
When was your last period?

Month Day Year
Date
When was your last cervical smear ?

Month Day Year
Date
What was the result?
Have your recent periods been regular?

Yes No
Are pre-menstrual symptoms a problem?

Yes No
Do you have any sexual problems?

Yes No
Do you have any bleeding between periods of after intercourse?

Yes No
Would you like to discuss hormone replacement therapy?

Yes No
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

YOUR HEALTH ASSESSMENT QUESTIONNAIRE

Your personal details

KEEPING YOUR GP INFORMED AND MONITORING FURTHER ACTION

PLEASE TELL US YOUR MAIN REASONS FOR ATTENDING

PLEASE TELL US ABOUT YOURSELF AND YOUR FAMILY

YOUR JOB HISTORY

YOUR LIFESTYLE

Your Medical History

YOUR MEDICAL HISTORY

In the past year, have you suffered from or been unable to work because of the following :

YOUR WELLBEING

ABOUT YOUR WORK

HEALTH QUESTIONS FOR MEN

HEALTH QUESTIONS FOR WOMEN