Patient questionnaire

The purpose of this questionnaire is to obtain an overview of your state of health and to provide the doctor with information about it. Please bring your vaccination booklet, medical reports or significant medical examination results with you.

All of the enclosed information is subject to medical confidentiality.

Name/Maiden name:

First Name:

Matricule:

Additional insurance number (AXA, Henner, Cigna, MSH, ...)

Date of birth:

Gender:

Address:

Postcode:

Residence:

Email address:

Private email address (without access for others) for medical results:

Mobile phone number:

Name and address of attending physician:

Employer:

Languages spoken:

Personal history:

Do you suffer from high blood pressure?YesNo
If yes, since when? Do you take any medication?

Do you suffer from diabetes mellitus?YesNo
If yes, since when? Do you take any medication?

Do you have high cholesterol?YesNo
If yes, since when? Do you take any medication?

Do you suffer from shortness of breath during physical activity?YesNo

Do you have a feeling of chest pain during physical activity?YesNo

Have you ever fainted?YesNo

Have you ever consulted a cardiologist?YesNo
If yes, when was the last time? What examinations have been made? Heart ultrasound? Stress test?

Do you smoke?YesNo
If yes, since when? How many cigarettes per day on average?

Have you stopped smoking?YesNo

Cumulative total number of years you smoked:

Approximate average number of cigarettes per day during this period:

Do you drink alcohol regularly?YesNo
If yes: average amount per week (glasses per week):

Do you engage in any sport that requires you to exert yourself physically?YesNo
If yes, which?

How many times per week? How many minutes per session on average?

Do you go for a walk regularly?YesNo

How many kilometers? How many times per week?

Do you eat five portions (1 portion = a handful)of fruit and vegetables per day on average?YesNo
If no, how many?

How many dairy products (125ml milk, 100ml yoghurt, 30g cheese) do you eat on average per day?

Do you have difficulty urinating?YesNo

Do you get up regularly during the night to go to the toilet?YesNo
if Yes, how many times per night on average?

Are you undergoing urological treatment?YesNo
If yes, when was the last time?

Are you undergoing gynaecological treatment?YesNo
If yes, when last? What tests have been done?

Do you still have your period?YesNo

At what age did you stop having your period?

Have you given birth?YesNo

Did you have gestational diabetes?YesNo

What was the birth weight of your child/children?

Do you have more than 50 moles?YesNo

Have you already had a skin cancer screening by a dermatologist?YesNo
If yes, when was the last visit?

Have you already had a colonoscopy/gastroscopy?YesNo
If yes, when? What was found?

Do you suffer from loss of appetite?YesNo

Do you have any discomfort or pain when swallowing?YesNo

Are there any changes in stool frequency/color or consistency?YesNo

Do you have any diseases concerning your eyes?YesNo

Are you undergoing ophthalmological treatment?YesNo
If yes, when last?

Do you have a cough?YesNo
If yes, since when?

Do you have sputum ?YesNo

Have you had a hoarse voice for more than 3 weeks?YesNo

Have you already had an operation?YesNo
If yes, with what and when?

Do you feel well in general?YesNo

Can you sleep well?YesNo

Do you feel tired when you wake up in the morning?YesNo

Have you lost weight in the last 3 months?YesNo
If yes, how many kg?

What medication are you currently taking? Please indicate dosage.

Food supplements?YesNo
Please indicate names.

Do you have any allergies?YesNo

When was your last tetanus/diphtheria vaccination?

Do you work with toxic/radioactive materials?YesNo

Family history:

Please indicate if any member of your immediate family (grandparents, aunts, uncles each whether maternal or paternal, parents, brothers, sisters or children) has suffered or is suffering from any of the following diseases:

HypertensionYesNo
who? from what age?

Diabetes mellitusYesNo
who? from what age?

Elevated cholesterol(hypercholesterolemia)YesNo
who? from what age?

Heart attack? bypass? Stents? sudden cardiac death?YesNo
who? at what age?

StrokeYesNo
who? from what age?

Tumors?YesNo
who? at what age? what type?

Glaucoma /cataract?YesNo
who? from what age?

Osteopenia or osteoporosis?YesNo
who? at what age?

Are there any other diseases worth mentioning?YesNo
who? from what age?