Health Check Questionnaire
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pemail
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Date
*
/
Day
/
Month
Year
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Gender assigned at birth
*
Male
Female
Email
*
example@example.com
General
Yes
No
Would you say you are in good general health?
Any severe fatigue or tiredness?
Any recent significant weight gain?
Any recent significant weight loss?
Any history of serious medical conditions in your immediate family?
Headaches and Balance
Yes
No
Do you get severe headaches or migraines?
Any numbness or pins and needle in your arms or legs?
Any episodes of dizziness or balance problems?
Vision
Yes
No
Have you had any recent changes in your vision?
Any episodes of double vision?
Any recent eye infections?
Any eye irritation or dryness or watering?
Ear, Nose and Throat
Yes
No
Have you had any hearing problems?
Any ringing or buzzing in your ears?
Any ear infections or discharge from your ears?
Any sinus or nasal problems?
Any recent dental problems?
Any mouth ulcers or sores?
Any difficulty chewing or eating?
Heart
Yes
No
Do you ever get chest pain?
Any palpitations or episodes of your heart racing?
Any swelling in your legs or ankles?
Respiratory
Yes
No
Have you being getting more short of breath than usual?
Any cough?
Any wheezing?
Any mucous or sputum?
Stomach and Bowel
Yes
No
Do you get frequent episodes of nausea or vomiting?
Any indigestion, heartburn or acid reflux?
Any problems swallowing - does food ever get stuck?
Any severe stomach or abdominal pains?
Any regular problem with diarrhoea?
Any regular problem with constipation?
Any recent changes in your bowel movement (frequency etc)?
Any persistent change in stool colour?
Any blood or mucous in the stool?
Urinary
Yes
No
Do you have any problems passing urine?
Are you passing urine more often?
Any pain or stinging passing urine?
Any blood in the urine?
Any urine incontinence or leakage?
Any urgency - having to rush to the toilet - to pass urine?
Do you get up more than once each night to pass urine?
Men's Health
Yes
No
Have you noticed a weak or slow stream when passing urine?
Do you have difficulty starting to pass urine?
Do you dribble urine after finishing?
Do you feel that you have an empty bladder after passing urine?
Do you occasionally (monthly recommended) examine your testes?
Any testicular lumps noticed or other concerns?
Female Health
Yes
No
Are you up to date with cervical screening (smears test)?
Are you on any hormone contraception?
Are you on hormone replacement therapy HRT?
Do you get periods?
Are your periods regular?
Have your periods become heavier?
Have your periods become lighter?
Any bleeding between periods?
Any bleeding after sexual intercourse?
Any pain during sexual intercourse?
Any pelvic pains at other times?
Any vaginal symptom concerns?
Do you occasionally (monthly recommeneded) examine your breasts?
Any breast lumps noticed or other concerns?
Back and Joints
Yes
No
Do you have any back or neck problems?
Any specific joint problems?
Any joint swelling or stiffness?
Skin
Yes
No
Any rashes or skin problems?
Any moles or other skin lesions of concern?
Mental Health
Yes
No
Do you have current concerns about low mood or depression?
Do you have current concerns about increased stress or anxiety?
Do you have any persistent problems with sleep?
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