dailyhealth.prime Medical Questionnaire Form Step 1 of 7 14% Name* First Middle Last Date of Birth* DD dot MM dot YYYY Email* Enter Email Confirm Email Please, provide truthful, accurate and complete answers to all questions listed below! General DataHeight in cm*Weight in kg*BMI* Questionnaire1) 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/institution2) 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/institution3) 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/institution5) 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/institution6) 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/institution7) 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/institution8) 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/institution9) 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/institution10) 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/institution11) 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/institution12) 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 Medication DetailsAre 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) PractitionerDo you have a family/ entrusted Doctor* Yes No Name* Mr.Mrs.MissMs.Dr.Prof.Rev. 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