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Executive Medical Navigation Questionnaireexecadmin2021-10-27T05:00:11+00:00

Executive Medical Navigation Questionnaire Download

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EXECUTIVE MEDICAL NAVIGATION QUESTIONNAIRE

Executive Medical Navigation 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 with any specific testing that may be required given your history.
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
5. a) Are you sensitive/allergic to any medication?*
- Yes
- No
If yes, what are they and what happens?
6. Is there a history of chronic joint pain, swelling, stiffness or redness?*
- Yes
- No
7. 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.)
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
7. Is there a history of unusual levels of anxiety or depression?
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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