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. Prefix First Middle Last Medical center/Medical Facility Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail TravelDo you plan to travel in the next 12 months?* Yes No Details Travel*Please provide specific details (Destination, Frequency, Duration, Duties/Reason) {all_fields}NameThis field is for validation purposes and should be left unchanged.