Health check-up form | Carebridges

Today's date:*

In what country and what city do you do your checkup:

Country:*

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

Instructions