Health check-up form | Carebridges

Instructions

Responding to this medical pre-questionnaire implies that you authorise a coordinating doctor to prepare your visit. Your case will be treated with strict confidentiality and exclusively by Health Professionals. If you require that the results of your check-up be transmitted to your GP, please specify this below (question II)

However if you are struggling to answer questions or if you do not want to answer for reasons that belong to you, you can speak directly with the doctor, the day of the consultation.

Today's date:*
In what country and what city do you do your checkup:
Country:*
France
Other: Country*
City:
hat dates are you available to your health check (one answer minimum required)
Choice 1:*
Choice 2:
Choice 3:
I. PERSONAL DETAILS
Last name:*
First name(s):*
*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Land-line telephone:
Mobile telephone:
Fax:
Email:*
Date of birth:*
Place of birth: *
Country of origin: *
Gender:*
Current marital status:
Professional status:*
Your weight? (kg)*
Your height? (m)*
Has your weight varied significantly over the past few months? *
- Yes
- No
If yes*
- Increasing
- Decreasing
II. DETAILS of your General Practitioner:
Last name:*
First name(s):*
Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Telephone: *
Fax:
Email:
Would you like the final report to be sent to your GP?*
- Yes
- No
III. MEDICAL ANTECEDANTS
Name any medical problems for which you have received treatment or been hospitalised.

Illnesses Started on what date? Remarks
What medication do you take at this current time?
IV. SURGICAL ANTECEDENTS
Have you ever undergone any surgical intervention(s)?*
- Yes
- No
If yes, please give details.*

Surgery type Year or age remarks
If other, please give details.
V. ALLERGIES
Do you have any allergies to medicines or other products? *
- Yes
- No
If yes, what sort?*
VI. VACCINATION
Are you up to date with your vaccinations? *
- Yes
- No
- I don’t know
What was the date of your last diphtheria injection?
What was the date of your last polio injection?
What was the date of your last anti-tetanus booster?
Do you take a yearly anti-flu vaccine?
- Yes
- No
- Don’t know
- Other yearly vaccine
Other vaccines (give details):
VII. LIFESTYLE HABITS
Do you smoke at this time?*
- Yes
- No
If yes, give details: (when did you start? How many cigarettes do you smoke per day?)
Have you ever smoked?*
- Yes
- No
If yes, give details: (when you started or the number of years or the year you gave up)
If no, do you live with or have you ever lived with someone who smokes? *
- Yes
- No
Do you drink alcoholic beverages?*
- Yes
- No
If yes, what do you drink? (wine, beer, liquor, etc…)
Give details of the quantity (number of glasses, bottles, cans consumed) per meal, outside of meals, per week?
VIII. FAMILY MEDICAL HISTORY
Is your father still alive?*
- Yes
- No
If yes, what is his age?
If no, please give details of the cause of death and his age at the time if known:
What significant health problems does or did he have? (diabetes, high blood pressure, heart attack or myocardial infarction, stroke, cancer, etc…); please give details:
Is your mother still alive?*
- Yes
- No
If yes, what is her age?
If no, please give details of the cause of death and her age at the time if known:
What significant health problems does or did she have? (diabetes, high blood pressure, heart attack or myocardial infarction, stroke, cancer, etc…); please give details:
Other family members:
What are the significant medical problems, if any, of other members of your family? (diabetes, high blood pressure, heart attack or myocardial infarction, stroke, cancer, etc…); please give details:
IX. OPTHALMOLOGY (Sight)
Do you wear glasses?*
- Yes
- No
When did you last visit your ophthalmologist? (if you don't know please let it empty)
What is your sight correction (L & R) ?
SECTION TEN IS ONLY FOR WOMEN
X. FOR WOMEN:
Age when you had your first periods ?
Do you use any contraceptives?*
- Yes
- No
- Don’t know
If yes, what type?
Number of pregnancies?*
Have you had any problems during your pregnancies? *
- Yes
- No
If yes, what kind?
Are you post-menopausal?*
- Yes
- No
- Don’t know
If yes, at what age did you have your periods for the last time? *
Do you take any hormonal treatments for the menopause?*
- Yes
- No
Which ones ?*
XI. ATTACHMENTS:
File
File
File
File
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