Health Screening Questionnaire - Brooklane Medical Centre - Bandon

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Brooklane Medical Health Clinic Bandon Cork

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Health Screening Questionnaire

Health Screening Questionnaire

Please fill out the form below and submit

1
Step 1

Personal details
2
Step 2

Social & Family
3
Step 3

Medical History
4
Step 4

Medical History
5
Step 5

Medical History
6
Step 6

Medical History

Date of Birth *

Address Form *

Address 1

Address 2

City

Marital Status *

Single

Married

Other

Sex *

Male

Female

Phone *

Email *

Confirm Email *

Step 2

Social History

Do you smoke ? *

Yes

No

Did you ever smoke ? *

Yes

No

Cigarettes/cigars per day *

When did you stop ?

Do you drink alcohol ? *

Yes

No

No. of units per week ? *

(Note: 1 unit alcohol = 1 glass wine, 1/2 pint beer, 1 shot spirits)

Do you exercise ? *

Yes

No

Sessions per week ? *

Do you have a past family history of Hypertension, diabetes etc *

Yes

No

If yes to above, please give details

Medical History

Part 1

1. Are you currently under medical care: *

Yes

No

If yes to 1, Medical details

2. Have you been in hospital otherwise ? *

Yes

No

If yes to 2, hospital details

3. Have you had any operations ? *

Yes

No

If yes to 3, operation details

4. Have you undergone X-Rays or tests ? *

Yes

No

If yes to 4, X-ray/test details

5. Are you taking any Medications ? *

Yes

No

If yes to 5, medication details

Do you suffer from or have you ever had?

A. Fainting - Dizziness - Fits - Blackouts - Epilepsy *

Yes

No

If yes to A. Details

B. A fear of height or open spaces (agoraphobia) *

Yes

No

If yes to B. Details

C. A fear of confined spaces (claustrophobia) *

Yes

No

If yes to C. Details

D. Recurrent headaches or Migraine *

Yes

No

If yes to D. Details

E. Mental illness or nervous trouble *

Yes

No

If yes to E. Details

F. Stress related illness *

Yes

No

If yes to F. Details

Medical History

Part 2

Do you suffer from or have you ever had?

G. Anxiety or depression *

Yes

No

If yes to G, details

H. Eye disorder or disturbance of vision *

Yes

No

If yes to H, details

I. Ear trouble, infections or deafness *

Yes

No

If yes to I, details

J. Did you ever work in a noisy environment *

Yes

No

If yes to J, details

K. Hay Fever or Sinusitis *

Yes

No

If yes to K, details

L. Asthma *

Yes

No

If yes to L, details

M. Bronchitis, Pneumonia or Pleurisy *

Yes

No

If yes to M, details

N. Chronic cough *

Yes

No

If yes to N, details

O. Shortness of breath or wheezing *

Yes

No

If yes to O, details

P. Tuberculosis *

Yes

No

If yes to P, details

Q. Any other chest compaint ? *

Yes

No

If yes to Q, details

R. High blood pressure *

Yes

No

If yes to R, details

Medical History

Part 3

Do you suffer from or have you ever had?

S. Chest pain, tightness or palpitations *

Yes

No

If yes to S, details

T. Rheumatic Fever *

Yes

No

If yes to T, details

U. Any other heart disease or disorder ? *

Yes

No

If yes to U, details

V. Varicose vein trouble or ankle swelling *

Yes

No

If yes to V, details

W. Anaemia *

Yes

No

If yes to W, details

X. Dermatitis, eczema or skin allergy *

Yes

No

If yes to X, details

Y. Psoriasis or other skin problem *

Yes

No

If yes to Y, details

Z. Difficulty with your appetite *

Yes

No

If yes to Z, details

1. Has there been any recent change in your weight? *

Yes

No

If yes to 1, details

2. Stomach trouble, indigestion/heartburn or ulcers *

Yes

No

If yes to 2, details

3. Jaundice or hepatitis *

Yes

No

If yes to 3, details

4. Chronic diarrhoea or constipation *

Yes

No

If yes to 4, details

Medical History

Part 4

Do you suffer from or have you ever had?

5. Urine or kidney trouble *

Yes

No

If yes to 5, details

6. Diabetes, thyroid disease or other glandular disorder *

Yes

No

If yes to 6, details

7. Back or neck trouble *

Yes

No

If yes to 7, details

8. Rheumatism, tendonitis or other joint trouble *

Yes

No

If yes to 8, details

9. Uterine, ovarian or menstrual trouble *

Yes

No

If yes to 9, details

10. Cancer or benign tumours or cysts *

Yes

No

If yes to 10, details

11. Any other significant medical condition *

Yes

No

If yes to 11, details

12. Are you allergic to any drugs or chemicals *

Yes

No

If yes to 12, details

13. Have you been off work in the last 2 years because of illness or injury? *

Yes

No

If yes to 13, details

14. Have you ever had to give up a job for health reasons or injury? *

Yes

No

If yes to 14, details

15. Have you ever had pain or discomfort when bending or lifting? *

Yes

No

If yes to 15, details

16. Do you ever get aches in your neck or shoulders? *

Yes

No

If yes to 16, details

17. Have you ever had a compensation claim against an employer because of an accident or ill health? *

Yes

No

If yes to 17, details

DECLARATION

I hereby certify that I voluntarily completed this questionnaire. The answers to these questions are accurate to the best of my knowledge.

Signature *

Date Picker *

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Form Submitted Successfully!

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BrookLane Medical, New Road, Bandon, Co. Cork, P72 YH72

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