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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

- Month - Day Year
Demographics
Name

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

Male Female
Date of Birth *

Month Day Year
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

Single Married Divorced Legally separated Widowed
Personal History
Please give details on your occupation
Does your occupation need you to work in day/night?

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

Yes No
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) ?

Yes No
Please give details if you take any Medications?
Please give details if you have any allergies?
Any Health Check-Ups done earlier?

Yes No
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 Gain Weight Loss Lack of energy Fatigue Insomnia Night sweats Sweat easily Excessive thirst Excessive Appetite Any History of Diabetes Anemia Poor Appetite Sleep disturbance Feeling hot Feeling Cold Other option
Skin

Rash skin sensitivity Itching Eczema Pimples Dry skin Dry scalp Warts Changes in skin Changes in hair Sores on skin Scores in mouth Hair loss Hair growth History of skin disease Other option
Oral/Dental

Teeth problems Dentures/implants Teeth clenching/grinding Tongue problems Mouth lesions Other option
Ear

Poor Hearing Hearing aids Wax Ear pain Ringing/noise Previous ear surgery Loud noise exposure Other option
Nose

Nose bleeds Post nasal drip Sinus infection Sinus Headaches Congestion Other option
Throat

Throat Pain Tonsil problems Swallowing problems Feeling of something stuck Voice problems Hoarse or altered voice Other option
Eyes

Double Vision Discharge Dryness Redness Cataract Blindness Eye pain Troubled Vision Blurry vision Other option
Allergy

Sneezing Runny Nose Itchy ears, eyes, or nose Hives (rash on skin) Other option
Sleep

Snoring Sleep Apnea Insomnia Choking/Gasping Restless leg Daytime sleepiness Other option
Musculoskeletal

Neck pain Back pain/spinal problems Fractures Muscle pain Swelling Joint/bone pain Other option
Hematologic / Blood Disorders

Bruise easily Anemia (pale looks) Leukemia/Lymphoma Varicose veins Bleeding disorders History of radiation Other option
Neurologic

Dizziness Lightheaded Fainting Facial pain Headaches Seizures Tremors Numbness Stroke Imbalance Memory loss Unexplained weakness Unstable Walk Other option
Cardovascular

High blood pressure Low blood pressure Chest pain Palpitations Abnormal rhythm Failed stress test Swelling in arms or legs Bleeding/clotting problems Irregular heart beat Prior Heart attack Other option
Respiratory

Difficulty breathing Asthma Pain on breathing Shortness of breath Cough with sputum Dry cough Seasonal allergies Snoring Wheezing Cough over 2 weeks History of Tuberculosis Coughing blood Other option
Digestive ( Gastrointestinal)

Nausea Vomiting Diarrhea Constipation Heartburn/acid reflux Indigestion Bloating Excessive gas Bloody or dark stool Abdominal Pain or cramping History of Gallstones IBD (Inflammatory Bowel Disease) History of Jaundice Other option
Genito-urinary

Pain with urination Urgency with urination Frequent urination Blood in urine Decreased urine flow Unable to hold urine Kidney problems/stones Impotency Frequent night time urination Urine/bladder infections Yeast infection Other option
Women Related questions
Menstrual History
Age of 1st menses
Bleeding

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

Irregular periods Painful periods Heavy periods Missed periods PMS Vaginal discharge Fibroids Infertility Breast lumps Nipple discharge Other option
Have you used Oral contraceptives?

Yes No
Number of pregnancies
Number of births
Age at which first child was born
Number of premature births
Post Delivery

Mood swings Sadness Anxiety Aggressiveness Anger Panic attacks Uncontrollable fear Easily stressed Inappropriate thoughts
Date of last PAP

- Day - Month Year
Date of last Mammo

- Day - Month Year

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ChuzDr Healthcare

Health Problems - Risk Assessment form

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