Identify your health problems - Risk Assessment Form

ChuzDr Healthcare

www.chuzdr.com confidential
Health Problems - Risk Assessment form

Ver 1.1 Please fill the form and share with your physician. This will help summarise your health related problems. Should you need an online consult please send us an email and we will arrange one for you. - For Women and Men 20 years and older.
Please note this form has been created to aid and is not an alternative to meeting and consulting with your doctor.

We have seen people do tests based on their understanding of their symptoms and based on which company gives the maximum number of tests at the least price, without consulting a doctor.

We believe this should not be done. This checklist of questions gives your doctor a good heads up of your health problems and will also help your doctor ask further questions so as to help build your ideal preventive health checkup plan.
Date

MonthDayYear
Demographics
Name

First NameLast Name
City *
Locality*
Enter EMail*
Mobile Phone *
Basic Information
Gender

MaleFemale
Date of Birth*

MonthDayYear
Height (feet.inches)
e.g. 5.7 needs to be entered fof 5 Feet 7 Inches
Weight (kgs.grams)
65.4 needs to enetred for 65.4 Kgs
Marital Status

SingleMarriedDivorcedLegally separatedWidowed
Personal History
Please give details on your occupation
Does your occupation need you to work in day/night?

DayNight
Do you exercise (how much)?
Do you smoke (how much)?
Do you drink (how much)?
Does your spouse or someone you live with Smoke?

YesNo
Do you use any illicit drugs (what kind, how often, how much)?
Do you consume caffeine (what kind, how much, how often)?
Does Your diet consist red meat (beef, pork, lamb or liver, processed meats) ?

YesNo
Please give details if you take any Medications?
Please give details if you have any allergies?
Any Health Check-Ups done earlier?

YesNo
What test scores were abnormal? (please give test name, score and date of test)
Review of Systems, Please indicate if you have any of the followings
General

Weight GainWeight LossLack of energyFatigueInsomniaNight sweatsSweat easilyExcessive thirstExcessive AppetiteAny History of DiabetesAnemiaPoor AppetiteSleep disturbanceFeeling hotFeeling ColdOther
Skin

Rashskin sensitivityItchingEczemaPimplesDry skinDry scalpWartsChanges in skinChanges in hairSores on skinScores in mouthHair lossHair growthHistory of skin diseaseOther
Oral/Dental

Teeth problemsDentures/implantsTeeth clenching/grindingTongue problemsMouth lesionsOther
Ear

Poor HearingHearing aidsWaxEar painRinging/noisePrevious ear surgeryLoud noise exposureOther
Nose

Nose bleedsPost nasal dripSinus infectionSinus HeadachesCongestionOther
Throat

Throat PainTonsil problemsSwallowing problemsFeeling of something stuckVoice problemsHoarse or altered voiceOther
Eyes

Double VisionDischargeDrynessRednessCataractBlindnessEye painTroubled VisionBlurry visionOther
Allergy

SneezingRunny NoseItchy ears, eyes, or noseHives (rash on skin)Other
Sleep

SnoringSleep ApneaInsomniaChoking/GaspingRestless legDaytime sleepinessOther
Musculoskeletal

Neck painBack pain/spinal problemsFracturesMuscle painSwellingJoint/bone painOther
Hematologic / Blood Disorders

Bruise easilyAnemia (pale looks)Leukemia/LymphomaVaricose veinsBleeding disordersHistory of radiationOther
Neurologic

DizzinessLightheadedFaintingFacial painHeadachesSeizuresTremorsNumbnessStrokeImbalanceMemory lossUnexplained weaknessUnstable WalkOther
Cardovascular

High blood pressureLow blood pressureChest painPalpitationsAbnormal rhythmFailed stress testSwelling in arms or legsBleeding/clotting problemsIrregular heart beatPrior Heart attackOther
Respiratory

Difficulty breathingAsthmaPain on breathingShortness of breathCough with sputumDry coughSeasonal allergiesSnoringWheezingCough over 2 weeksHistory of TuberculosisCoughing bloodOther
Digestive ( Gastrointestinal)

NauseaVomitingDiarrheaConstipationHeartburn/acid refluxIndigestionBloatingExcessive gasBloody or dark stoolAbdominal Pain or crampingHistory of GallstonesIBD (Inflammatory Bowel Disease)History of JaundiceOther
Genito-urinary

Pain with urinationUrgency with urinationFrequent urinationBlood in urineDecreased urine flowUnable to hold urineKidney problems/stonesImpotencyFrequent night time urinationUrine/bladder infectionsYeast infectionOther
Women Related questions
Menstrual History
Age of 1st menses
Bleeding

ExcessScanty
Number of days between menses
1st day of last menses
Age of menopause
Gynecological

Irregular periodsPainful periodsHeavy periodsMissed periodsPMSVaginal dischargeFibroidsInfertilityBreast lumpsNipple dischargeOther
Have you used Oral contraceptives?

YesNo
Number of pregnancies
Number of births
Age at which first child was born
Number of premature births
Post Delivery

Mood swingsSadnessAnxietyAggressivenessAngerPanic attacksUncontrollable fearEasily stressedInappropriate thoughts
Date of last PAP

DayMonthYear
Date of last Mammo

DayMonthYear

ChuzDr Healthcare

Health Problems - Risk Assessment form

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