Executive Health Form


Executive Health Questionnaire
Basic Information
First Name *
Last Name *
Date of Birth * MM/DD/YYYY
Phone Number & Physical Address *
Basic Medical Information
PHN# (Care Card) *
Family Doctor
Pharmacy
Surgical History
List all current medication and doses
Allergies
In-Depth Health Issues - ENT
Hearing, sense of smell, nosebleeds
In-Depth Health Issues - Nervous System
Headaches, migraines, dizziness
Memory loss, loss of concentration
Loss or change in vision
In-Depth Health Issues - Digestive System
Gas, indigestion, flatulence
Diarrhea, constipation, blood in stool
Upset stomache, black stool, hemorrhoids
In-Depth Health Issues - Cardiovascular
Chest Pain
Varicose veins, ankle swelling
Diabetes
High blood pressure, high cholesterol
Heart Murmur
Stress Test
In-Depth Health Issues - Urinary
Urination
How often do you urinate per night?
In-Depth Health Issues - Pulmonary
Asthma, out of breath episodes, morning cough
In-Depth Health Issues - Mental Health
Mental illness, depression, anxiety, insecurity
In-Depth Health Issues - Other
Cancer
Gout, glaucoma, arthritis
Osteoporosis
Thyroid Disease
In-Depth Health Issues - Musco-Skeletal
Head, neck, limb, spine injuries
In-Depth Health Issues - Skin
Psoriasis, Acne, Eczema, moles, itchiness
In-Depth Health Issues - Weight
Weight loss, weight gain, constant fluctuations
Male Health
Sexual loss, sexual desire, erectile disfunction
Fertility, Vasectomy
Female Health
Breast Medical Issues
Gynaecological, sexual problems
Mammogram
PAP Smear
Age of onset menstruation
Last Menstrual Period MM/DD/YYYY
Pregnancy History
Age of onset menopause
History & Lifestyle
Family History
Social History
Alchohol Intake
Caffeine Intake
Eating Habits
Sleeping Habits
Fitness Routine
Emotional Well-Being
Stress Level
Leisure Time
Smoking Habits
Additional Comments
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