Skip to content

+43.1.300 81 81contact@dhig.net

Toggle menu

Home

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!

Save and Continue Later

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

Save and Continue Later

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

Save and Continue Later

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)

Save and Continue Later

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

Save and Continue Later

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

Save and Continue Later

{all_fields}
Phone
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Privacy Policy
Imprint
Terms & Conditions
Cookie Policy
Imprint
Disclaimer

copyright by dhig GmbH 2020

English

Manage Cookie Consent

We use cookies to optimize our website and our service.

Functional Functional Always active

The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.

Preferences Preferences

The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.

Statistics Statistics

The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.

Marketing Marketing

The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.

Manage options Manage services Manage vendors Read more about these purposes

Preferences

{title} {title} {title}

Manage Cookie Consent

We use cookies to optimize our website and our service.

Functional Functional Always active

The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.

Preferences Preferences

The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.

Statistics Statistics

The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.

Marketing Marketing

The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.

Manage options Manage services Manage vendors Read more about these purposes

Preferences

{title} {title} {title}