Health Check Form

Meritial Status
Single Married Divorced Widowed

Name

Surname

Email

Birth Day

Occupation

Height

Weight

BMI Index

Country

Phone Number

Address/City/State

Smoking: (If yes, state quantity):

Alcohol: (If yes, state quantity):

Other Substances:(If yes, specify)

Date of last menstrual period:

Prescriptions/Medications:

Number of pregnancies:

Number of live births:

Last childbirth (Date):

Method of birth control: (Specify)

If menopausal, date of onset:

Drug Use:
Yes No

Drug allergies/adverse drug reaction:
Yes No

Reaction to Anaesthesia:
Yes No

Blood Transfusion:
Yes No

Sexually Transmitted Disease:
Yes No

Hepatitis:
Yes No

HIV
Yes No

Breast Feeding:
Yes No

Hereditary health concerns:
Yes No

Diabet
Yes No

Insulin:
Yes No

Oral antidiabetic pills:
Yes No

Blood Pressure:
Yes No

Cholesterol:
Yes No

Cancer:
Yes No

Kidney Disease:
Yes No

Epilepsy or Seizures:
Yes No

Anemia:
Yes No

Arthritis:
Yes No

Asthma/Emphysema:
Yes No

Gallbladder Disease:
Yes No

Difficulty in Swallowing/Stroke:
Yes No

Joint Pain:
Yes No

Constipation or Diarrhea:
Yes No

Abnormal Vaginal Bleeding:
Yes No

Swollen Glands:
Yes No

Anxiety:
Yes No

Pelvic Pain:
Yes No

Reflux:
Yes No

Chest Pain:
Yes No

Shortness of Breath:
Yes No

Difficulty Sleeping/Apnea:
Yes No

Nausea:
Yes No

Dizziness:
Yes No

Rectal Bleeding:
Yes No

Burning w/Urination:
Yes No

Hot Flashes:
Yes No

Murmur (Heart Disease):
Yes No

Cardiac failure (Heart Disease):
Yes No

Rhythm disturbances (Heart Disease):
Yes No

Surgical history (State any surgical procedure):

Surgical history date

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