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dailyhealth.prime Medical Questionnaire Form

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Name*
First Middle Last
Date of Birth*
DD dot MM dot YYYY
Email*
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Please, provide truthful, accurate and complete answers to all questions listed below!

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General Data
Height in cm*
Weight in kg*
BMI*

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Questionnaire
1) Within the past 10 years, have you or any Dependent(s) been treated, diagnosed, tested, hospitalized, or recommended for treatment for any of the following:*
- Seizures or seizure disorder; paralysis; multiple sclerosis; or any disorder of the central nervous system
- Mental retardation; any mental, behavioral, emotional, or eating disorder; anxiety, depression, neurosis or psychosis; psychotherapy; psychological, or any form of counseling or therapy
- High blood pressure; heart attack, stroke, chest pain or palpitations, murmur, varicose veins, blood clot, anaemia, or any other blood heart, or circulatory disorder or condition
- Asthma; emphysema; bronchitis; sinusitis; pneumonia; allergies; apnea; or any breathing difficulty, lung or respiratory disease, disorder or condition
- Colitis; chronic diarrhoea, or intestinal problems; hernia; ulcer of the stomach or duodenum; haemorrhoids or rectal disorder; hepatitis or liver disorder; gallbladder, pancreas, oesophagus, or any other digestive disorder or condition
- Cancer, tumour, growth, cyst, enlarged lymph nodes; psoriasis, keratosis, lesions of the skin or mouth or any other skin disorder
- Disease or disorder of the breast; kidney; kidney stones; bladder; prostrate; abnormal pSa, or any other urinary disorder or infection
- Diseases or disorder of the genital or reproductive system; herpes, any sexually transmitted disease; endometriosis, or abnormal pap smear
- Been treated for infertility; taken any medication, or advised to seek treatment, medication, diagnostic tests or surgery for infertility
- Arthritis; rheumatism; gout; tMJ (temporomandibular joint syndrome); any injury to or disease or disorder of the spine, back, jaw, bones, muscles, or joints; joint replacement
- Pituitary, adrenal, or thyroid disorder; lupus; diabetes
- Cataracts; glaucoma; or any eye disorder; hearing loss; or any ear, nose, or throat disorder
- Alcoholism; alcohol, drug or substance abuse or dependency
- Acquired immune Deficiency Syndrome (aiDS), aiDS-Related complex (aRc), HiV positive, or other immune disorders
- NONE OF THE ABOVE
Details Question 1*
Please provide specific details (including explanation of grounds) Condition/ Diagnosis, Treatment (Serveries/Treatment), Treatment dates From/To, Ongoing or date of recovery, Name, location or telephone number of physician, hospital/institution
2) Have you been advised to have a surgical procedure, hospitalization, or undergo testing that has not yet been completed*
- Yes
- No
Details Question 2*
Please provide specific details (including explanation of grounds) Condition/ Diagnosis, Treatment (Serveries/Treatment), Treatment dates From/To, Ongoing or date of recovery, Name, location or telephone number of physician, hospital/institution
3) Are you currently pregnant*
- Yes
- No
3) Expected Delivery Date*
DD dot MM dot YYYY
Is there a history of complications with previous Pregnancies or are complications anticipated with this Pregnancy*
- Yes
- No
Is this Pregnancy the result of infertility treatment*
- Yes
- No
4) Have you gained or lost more than 12 kilos or 25 pounds during the last 12 months*
- Yes
- No
Details Question 4*
Please provide specific details (including explanation of grounds) Condition/ Diagnosis, Treatment (Serveries/Treatment), Treatment dates From/To, Ongoing or date of recovery, Name, location or telephone number of physician, hospital/institution
5) Have you ever been declined, postponed, rated, or limited for life, health, or accident insurance?*
- Yes
- No
Details Question 5*
Please provide specific details (including explanation of grounds) Condition/ Diagnosis, Treatment (Serveries/Treatment), Treatment dates From/To, Ongoing or date of recovery, Name, location or telephone number of physician, hospital/institution
6) Have you been hospitalized in the last 10 years for any reason?*
- Yes
- No
Details Question 6*
Please provide specific details (including explanation of grounds) Condition/ Diagnosis, Treatment (Serveries/Treatment), Treatment dates From/To, Ongoing or date of recovery, Name, location or telephone number of physician, hospital/institution
7) Have you or any dependent(s) consulted or been advised to consult a medical practitioner, or do you suffer from any significant physical impairment, deformity sickness, or injury other than revealed in questions above*
- Yes
- No
Details Question 7*
Please provide specific details (including explanation of grounds) Condition/ Diagnosis, Treatment (Serveries/Treatment), Treatment dates From/To, Ongoing or date of recovery, Name, location or telephone number of physician, hospital/institution
8) Do you engage in any profession, sport, or hobby that could be considered hazardous*
- Yes
- No
Details Question 8*
Please provide specific details (including explanation of grounds) Condition/ Diagnosis, Treatment (Serveries/Treatment), Treatment dates From/To, Ongoing or date of recovery, Name, location or telephone number of physician, hospital/institution
9) Do you receive any disability pension or work accident pension*
- Yes
- No
Details Question 9*
Please provide specific details (including explanation of grounds) Condition/ Diagnosis, Treatment (Serveries/Treatment), Treatment dates From/To, Ongoing or date of recovery, Name, location or telephone number of physician, hospital/institution
10) Are you currently receiving an ongoing treatment?*
- Yes
- No
Details Question 10*
Please provide specific details (including explanation of grounds) Condition/ Diagnosis, Treatment (Serveries/Treatment), Treatment dates From/To, Ongoing or date of recovery, Name, location or telephone number of physician, hospital/institution
11) Is there any planned treatment known*
- Yes
- No
Details Question 11*
Please provide specific details (including explanation of grounds) Condition/ Diagnosis, Treatment (Serveries/Treatment), Treatment dates From/To, Ongoing or date of recovery, Name, location or telephone number of physician, hospital/institution
12) Have you undergone X-ray or MRI screening for any reason*
- Yes
- No
Details Question 12*
Please provide specific details (including explanation of grounds) Condition/ Diagnosis, Treatment (Serveries/Treatment), Treatment dates From/To, Ongoing or date of recovery, Name, location or telephone number of physician, hospital/institution

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Medication Details
Are there any medications or drugs that are currently prescribed for you*
- Yes
- No
Details Medication*
Please provide specific details (Medication/drug Name, Dosage, Frequency, Reason for taking)

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Practitioner
Do you have a family/ entrusted Doctor*
- Yes
- No
Name*
Prefix First Middle Last
Medical center/Medical Facility
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email

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Travel
Do you plan to travel in the next 12 months?*
- Yes
- No
Details Travel*
Please provide specific details (Destination, Frequency, Duration, Duties/Reason)

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Name
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