Medical Questionnaire
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Jack
Kim
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Contact Details
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Phone Number
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Gender
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Date of Birth
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Height
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Current Weight (Approx)
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Are you registered with a Doctor where you currently Live?
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Doctor Name
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First Name
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Doctor Address
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Street Address
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State / Province
Postal / Zip Code
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Afghanistan
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American Samoa
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Doctor Number
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Health Questionnaire
Statement of Present Health
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Excellent
Very Good
Good
Fair
Please Explain
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Do you take Non-Prescriptive Drugs routinely?
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Yes
No
Provide Description
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Do you take Prescriptive Drugs routinely?
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Yes
No
Provide Description
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Do you take Recreational Drugs?
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Yes
No
Provide Description
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Are you under the care of a Physician now?
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Yes
No
Provide Description
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Do you have any Allergies?
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Yes
No
Provide Description
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Have you ever had any of the following:
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Yes
No
Not Sure
Abnormal Chest X-Ray
Allergies
Anaemia/Blood Disorder
Anxiety Disorder
Asthma
Attention Deficit Hyperactivity Disorder (ADHD)
Auditory Processing Disorder
Autism
Bipolar Disorder
Blindness
Car, Sea or Air Sickness
Chronic Cough
Chronic or Frequent Colds
Conduct Disorder (CD)
Deafness
Depression
Dizziness/Fainting Spells
Down Syndrome
Dyscalculia
Dysgraphia
Dyslexia
Dyspraxia
Ear, Nose or Throat Trouble
Eating Disorder
Epilepsy or Fits
Excessive Use of Alcohol
Frequent Severe Headache or Migraine
Gall Bladder Trouble
Hearing Impairment
Heart Trouble
High/Low Blood Pressure
HIV
Intestinal Problems
Jaundice or Hepatitis
Joint Problems
Juvenile Arthritis
Kidney/Bladder Trouble
Leukaemia
Multiple Sclerosis
Muscular Dystrophy
Nervous Trouble of Any Sort
Oppositional Defiant Disorder (ODD)
Other Sexually Transmitted Diseases
Recurrent Back Pain
Schizophrenia
Sensory Processing Disorder
Severe Tooth/Gum Problem
Skin Disease
Stomach, Liver Trouble
Syphilis
Thyroid Trouble
Tuberculosis
Tumour, Growth, Cyst, Cancer
Use Tobacco
Visual/Eye Impairment
Weight Gain Related Issues
Weight Loss Related Issues
Please provide specific details with dates
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Number of sick days in the last 2 years
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101+
Reason for Sickness
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