Teri's Health Services
Questionnaire
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History
Check all those that apply
Arthritis/Gout
Asthma
Blood clots
Circulation problems
Colitis/bowel disease
Congestive heart failure (CHF)
Coronary artery disease (CAD)
COVID-19/Flu-current
Diabetes
Emphysema/COPD
Heart attack
Heartburn/GERD
High blood pressure
HIV/AIDS
Renal failure or disease
Stomach ulcers
Stroke
Thyroid disease
Tuberculosis
Urinary tract infection (UTI)
None
Other
Surgical History - check all that apply
No surgical history
Abdominal surgery
Appendectomy
Brain
Breast biopsy
Broken bones/fractures
CABG/Heart bypass
Cardiac stent
Colon removal
C-section
Gall bladder removal
Hernia repair
Hysterectomy
Joint replacement
Mastectomy
Tonsillectomy
Vasectomy
Other
Are you currently pregnant or may be pregnant or breast feeding?
*
Yes
No
Do you have a history of cancer and/or undergoing chemotherapy?
*
Yes
No
If yes to chemotherapy, have you received chemotherapy, or are you scheduled to start chemotherapy, within the past/next two (2) weeks?
Yes
No
N/A
Do you currently or in the past use nicotine?
Yes in the past I did, but no longer use nicotine of any type
Yes I currently use nicotine
No I never used nicotine in the past and I currently do not use nicotine
Other
Do you have any of these symptoms? Check all that apply.
*
Fever/chills
Fatigue
Weight loss or gain of 5 lbs or more
Have none of these symptoms
Other
Do you have any of these listed symptoms regarding eyes/ears/nose/throat? Check all that apply.
*
Vision change
Pain in eyes
Hearing problems or ear issues
Smell and nose problems
Dizziness
Sinus congestion/pressure
Swelling/lumps in throat
Problems with your throat or swallowing
I have none of these symptoms
Other
Do you have any of these cardiovascular symptoms? check all that apply.
*
Chest pain
Palpitations
Edema/Swelling in legs
I have none of these symptoms
Other
Do you have any of these respiratory symptoms? Check all that apply.
*
Abdominal pain
Constipation
Heartburn/ingestion
Difficulty swallowing
Nausea/vomiting
Frequent urination
Painful urination
Blood in urine or stool
Urinary or stool incontinence
I have none of these
Other
Do you have any of these musculoskeletal symptoms? check all that apply.
*
Back or neck pain
Joint pain or swelling
Muscle pain
I have none of these symptoms
Other
Do you have any of these skin symptoms? check all that apply.
Rash
Skin growth
New or changed moles
Persistent itch
I have none of these symptoms
Other
Do you have any of these neurological symptoms? check all that apply.
Headaches
Change in thinking or processing
Memory loss
Trouble speaking
Weakness
Loss of coordination
Numbness
Falling or unsteady gate
I have none of these symptoms
Other
Do you have any of these endocrine symptoms? check all that apply.
Excessive/increased thirst
Heat/cold intolerance
Too hot or too cold
I have none of these symptoms
Other
Current weight
Current height
Any concerns about your mental health?
Any concerns about your physical health?
Do you have a history of alcohol abuse or illegal drug use?
Yes
No
Have you ever been hospitalized?
Yes
No
Do you have any self-declared disabilities? If yes, explain
Do you use nicotine? If yes, history of use and amount.
What is your current or past occupation?
If the person completing form is not the person signing up for treatment, what relationship are you to Client?
Signature
*
Date
*
-
Month
-
Day
Year
Date
Guardian
First Name
Last Name
Signature
Submit
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