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
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
Submit
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