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Executive Medical Assessment Questionnaire
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2021-10-27T04:59:15+00:00
Executive Medical Assessment Questionnaire Download
If you prefer to download and submit manually, click this button.
EXECUTIVE MEDICAL ASSESSMENT QUESTIONNAIRE
Executive Medical Assessment Questionnaire Online
Thank you for taking the time to complete this questionnaire. Completing your medical history prior to your appointment date will allow our medical professionals to review your past medical history and balance routine testing and recommend any specific testing that may be required given your history. Once you have completed the questionnaire.
If further information or assistance is required, please contact us at (416) 418-7078
A) Medical History
Please select all that apply
1. Do you have a history of any significant medical illnesses such as: (choose all that apply)
*
High Blood Pressure
Shortness of Breath
Chest Pain
Stroke
Emphysema/COPD
Arthritis
Cancer(s)
Lung Disease
Asthma
Other Illnesses
If Other, please explain below
2. Please list any previous and scheduled surgeries (including dates if applicable).
3. a) Are you taking any medication?
*
Yes
No
Please list all current medications (including name and dosage).
b) Do you have a copy of your updated vaccination history?
Yes
No
If yes, Please provide
4. a) When was the date of your last physical?
*
MM slash DD slash YYYY
b) When was the date of your last pap (if applicable)?
MM slash DD slash YYYY
c) When was the date of your last mammogram (if applicable)?
MM slash DD slash YYYY
d) When was the date of your last colonoscopy?
MM slash DD slash YYYY
e) When was your last eye exam?
MM slash DD slash YYYY
f) When was your last hearing test?
MM slash DD slash YYYY
g) When was the date of your last bloodwork?
MM slash DD slash YYYY
h) Have you ever had cardiac testing?
*
Yes
No
5. a) Are you sensitive/allergic to any medication?
*
Yes
No
b) Do you have any food allergies?
*
Yes
No
If yes, what are they and what happens?
6. Is there a history of unusual levels of anxiety or depression?
*
Yes
No
B) Family History
1. Does/do any of your family members have any of the following medical problems? Choose all that apply.
Heart Disease
Cancer
Serious Infection
Diabetes
High Cholesterol
Stroke
Lung Disease/Emphysema/COPD
High Blood Pressure
Other Illnesses
Please provide details (who, when, etc.):
C) Social History
1. Are you satisfied with your present lifestyle and daily responsibilities?
*
Yes
No
2. What is your assessment of your present state of physical fitness?
*
Poor
Below Average
Average
Above Average
Excellent
Do you drink Alcohol?
*
Yes
No
If yes, how often?
4. Have you ever smoked?
*
Yes
No
5. Do you smoke now?
*
Yes
No
If yes, how many packs per day?
6. Have you ever used recreational drugs?
*
Yes
No
If yes, what type and how often?
7. What are the weakest points of your overall health? (e.g. smoking, alcohol, stress, sedentary lifestyle, family history, etc.)
8. Do you have any specific diet that you need to follow?
9. Are there any topics regarding nutrition/your diet you would like to discuss?
D) Follow Up
1. Do you currently have a family physician?
*
Yes
No
2. If yes, would you like them to be copied on any EMC reports/arranged referrals?
*
Yes
No
E) Other Pertinent Medical Information
1. Are there other points that you feel should be included in your history form?
We thank you for completing this questionnaire. Once received, a member of our team will contact you with further instructions.
To the best of my knowledge, the above information is correct
*
By clicking this box, you agree that the information presented is accurate to date.
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