Post by Admin on Sept 30, 2021 11:51:27 GMT
questionnaire/health History
PRIVACY ACT STATEMENT: This statement is provided pursuant to the Privacy Act of 1974 universal law medical agreement. all information provided is confidential.
please Attach consent to treat form here:
Have you ever had surgery? If "yes," please list and explain below
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?
If "yes," please describe below
**Do you have or have you ever had the following: **Yes..No...Not Sure**
1. Head/brain injuries or illnesses (e.g., concussion)
2. Seizures, epilepsy
3. Eye problems (except glasses or contacts)
4. Ear and/or hearing problems
5. Heart disease, heart attack, bypass, or other heart
problems
6. Pacemaker, stents, implantable devices, or other heart
procedures
7. High blood pressure
8. High cholesterol
9. Chronic (long-term) cough, shortness of breath, or other
breathing problems
10. Lung disease (e.g., asthma)
11. Kidney problems, kidney stones, or pain/problems with
urination
12. Stomach, liver, or digestive problems
13. Diabetes or blood sugar problems
Insulin used
14. Anxiety, depression, nervousness, other mental health
problems
15. Fainting or passing out
16. Dizziness, headaches, numbness, tingling, or memory
loss
17. Unexplained weight loss
18. Stroke, mini-stroke (TIA), paralysis, or weakness
19. Missing or limited use of arm, hand, finger, leg, foot, toe
20. Neck or back problems
21. Bone, muscle, joint, or nerve problems
22. Blood clots or bleeding problems
23. Cancer
24. Chronic (long-term) infection or other chronic diseases
25. Sleep disorders, pauses in breathing while asleep,
daytime sleepiness, loud snoring
26. Have you ever had a sleep test (e.g., sleep apnea)?
27. Have you ever spent a night in the hospital?
28. Have you ever had a broken bone?
29. Have you ever used or do you now use tobacco?
30. Do you currently drink alcohol?
31. Have you used an illegal substance within the past two
years?
32. Have you ever failed a drug test or been dependent on
an illegal substance?
Other health condition(s) not described above:
I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may cause severe penalties per the laws of San Carlos that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35 and will be severely punished.
Verification
Signature: Date:
Admission Signature:
PRIVACY ACT STATEMENT: This statement is provided pursuant to the Privacy Act of 1974 universal law medical agreement. all information provided is confidential.
please Attach consent to treat form here:
Have you ever had surgery? If "yes," please list and explain below
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?
If "yes," please describe below
**Do you have or have you ever had the following: **Yes..No...Not Sure**
1. Head/brain injuries or illnesses (e.g., concussion)
2. Seizures, epilepsy
3. Eye problems (except glasses or contacts)
4. Ear and/or hearing problems
5. Heart disease, heart attack, bypass, or other heart
problems
6. Pacemaker, stents, implantable devices, or other heart
procedures
7. High blood pressure
8. High cholesterol
9. Chronic (long-term) cough, shortness of breath, or other
breathing problems
10. Lung disease (e.g., asthma)
11. Kidney problems, kidney stones, or pain/problems with
urination
12. Stomach, liver, or digestive problems
13. Diabetes or blood sugar problems
Insulin used
14. Anxiety, depression, nervousness, other mental health
problems
15. Fainting or passing out
16. Dizziness, headaches, numbness, tingling, or memory
loss
17. Unexplained weight loss
18. Stroke, mini-stroke (TIA), paralysis, or weakness
19. Missing or limited use of arm, hand, finger, leg, foot, toe
20. Neck or back problems
21. Bone, muscle, joint, or nerve problems
22. Blood clots or bleeding problems
23. Cancer
24. Chronic (long-term) infection or other chronic diseases
25. Sleep disorders, pauses in breathing while asleep,
daytime sleepiness, loud snoring
26. Have you ever had a sleep test (e.g., sleep apnea)?
27. Have you ever spent a night in the hospital?
28. Have you ever had a broken bone?
29. Have you ever used or do you now use tobacco?
30. Do you currently drink alcohol?
31. Have you used an illegal substance within the past two
years?
32. Have you ever failed a drug test or been dependent on
an illegal substance?
Other health condition(s) not described above:
I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may cause severe penalties per the laws of San Carlos that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35 and will be severely punished.
Verification
Signature: Date:
Admission Signature: