Pre Appointment Questionnaire

Health History Questionnaire

Personal information

Name
Name
First
Last

Health History

Medical condition/s you are applying for

Concerning this diagnosis

Have you seen specialists, where you admitted to hospital, and what tests where done (blood/x-rays/scans etc)?

List your prescribed drugs

For this condition, please list your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers and alternative treatments like herbs etc (also list any medication you tried before but stopped because it didn’t work or due to side effects or allergies)

Allergies to medications

Please list all medications, prescribed, vitamins, herbal etc for your other medical problems.

Mental Health

Have you ever had a psychotic episode?
Do you feel depressed/stressed? Does this condition affect it?
Do you panic when stressed?
Do you have problems with eating or your appetite? Does this condition affect it?
Do you cry frequently?
Have you ever attempted suicide?
Have you ever seriously thought about hurting yourself?
Do you have trouble sleeping? Does this condition affect it?
Have you ever been to a counselor?
Do you smoke?
Do you use any illicit drugs?
Do you drink alcohol?

Maximum file size: 52.43MB

Section B

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.