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Health Evaluation Form
The following questionaire is a comprehensive look at your health. It will take about 5 minutes to complete
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1
Name
*
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First Name
Last Name
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2
Gender
*
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Male
Female
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3
Email
*
This field is required.
example@example.com
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4
Phone Number
*
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Area Code
Phone Number
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5
Do you Smoke?
*
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Yes
No
Previously
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6
What do you smoke?
Shisha
Tobacco
Cigarettes
Cigars
Electronic cigarette
Other
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7
How long have you smoked for?
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8
How many per day?
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9
Are you interested in stopping smoking?
YES
NO
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10
Do you drink alcohol?
YES
NO
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11
How often do you drink alcohol?
Daily
1-2 times a week
3-4 times a week
Weekly
Monthly
No I Don't Drink
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12
How many units of alcohol?
Units
Alcopop (275ml) - 1.5 Units
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Small glass of wine 125ml - 2 Units
Row 1, Column 0
Bottle of lager/beer/cider 330ml - 1.7 Units
Row 2, Column 0
Can of lager/beer/cider 440ml - 2 Units
Row 3, Column 0
Pint of lower-strength lager/beer/cider - 2 units
Row 4, Column 0
Standard glass of red/white/rosé wine 175ml - 2.1 Units
Row 5, Column 0
Pint of higher-strength lager/beer/cider - 3 Unit
Row 6, Column 0
Large glass of red/white/rosé wine 250ml - 3 Units
Row 7, Column 0
Alcopop (275ml) - 1.5 Units
Small glass of wine 125ml - 2 Units
Bottle of lager/beer/cider 330ml - 1.7 Units
Can of lager/beer/cider 440ml - 2 Units
Pint of lower-strength lager/beer/cider - 2 units
Standard glass of red/white/rosé wine 175ml - 2.1 Units
Pint of higher-strength lager/beer/cider - 3 Unit
Large glass of red/white/rosé wine 250ml - 3 Units
Units
Row 0, Column 0
Units
Row 1, Column 0
Units
Row 2, Column 0
Units
Row 3, Column 0
Units
Row 4, Column 0
Units
Row 5, Column 0
Units
Row 6, Column 0
Units
Row 7, Column 0
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13
How often do you exercise?
Daily
1-2 times a week
3-4 times a week
4-6 times a week
I don't any exercise
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14
What type of exercise you do?
Walking
Running
Golf
Gym
Other
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15
How many portions of Fruit/Vegetables do you eat per day?
0
1-2
3-4
4-5
More than 5
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16
Do you feel stressed due to your work, home life or financial pressures?
Yes
No
Intermittently
Regularly
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17
Do you wish to discuss this further?
YES
NO
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18
If Yes
are you low in mood
are you suffering from anxiety
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Feeling tired and or having little energy
Feeling bad about yourself
Trouble concentrating on things
Poor appetite or overeating
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19
Have you ever suffered from? (Please tick relevant boxes)
Heart attack or Angina
Diabetes
Rheumatic Fever
High Blood Pressure
High Cholesterol
Asthma
Bronchitis / Emphysema
Thyroid Disorder
Allergies
Migraine
Blackouts / Seizures
Stroke / Mini – stroke
Cancer
Traumatic Injury / broken bones
Previous surgeries
Other / Comments
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20
Provide further information
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21
If you have a family history of any of the conditions, please provide details below
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22
If selected Other
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23
If you have ever been hospitalised in the past or had any operations / Surgical procedures, please provide details below
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24
Please list any prescribed medication that you are currently taking. And also include any over the counter treatments such as herbal remedies
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25
Do you regularly examine your testicles?
Yes
No
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26
If No
Would you be interested in learning?
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27
Have you ever had any lumps or swelling in your testicles?
Yes
No
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28
Do you get up at night to pass urine on a regular basis?
Yes
No
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29
If yes, how many times a night?
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30
Have you noticed any change in the flow, rate or stream of your urine?
Yes
No
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31
Do you ever have a prostate examination / PSA (prostate) blood test?
Yes
No
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32
Do you have pain on passing urine?
Yes
No
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33
Have you ever noticed blood in your urine?
Yes
No
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34
Do you ever have any problems with erections?
Yes
No
Intermittently
Regularly
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35
Would you like to discuss anything related to sexual health?
Yes
No
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36
Have you ever had a cervical smear test?
Yes
No
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37
If yes was your most recent one normal?
Yes
No
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38
Are you registered with Cervical Check program?
Yes
No
Don't Know
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39
Do you regularly examine your Breasts?
Yes
No
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40
If No
Would you like to learn how?
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41
Have you ever noticed any lumps or swelling in your breasts?
Yes
No
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42
Have you ever had a mammogram?
Yes
No
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43
If yes was your most recent one normal?
Yes
No
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44
Are you registered with Breast Check program?
Yes
No
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45
When was your last period?
-
Date
Year
Month
Day
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46
Have you ever been pregnant?
Yes
No
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47
Fertility
Do you have any fertility concerns?
Have you activily tried to become pregnant?
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48
How many children or births have you had?
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49
Are you currently using contraception?
Yes
No
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50
If yes what type?
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51
Are you concerned about menopausal symptoms?
Yes
No
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52
Are your periods irregular, particularly painful or heavy?
Yes
No
Not applicable
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53
Have you experienced any vaginal bleeding / discharge that you think is abnormal?
Yes
No
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54
Do you ever have difficulty controlling your bladder / getting to the toilet in time?
Yes
No
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55
Would you like to discuss anything related to sexual health or infertility?
Yes
No
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56
Please provide further information?
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57
Do you have a normal bowel movement?
YES
NO
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58
Any recent changes in bowel movements?
YES
NO
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59
Have you noticed any blood, mucus, change in color?
YES
NO
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60
Is there any other aspect of your health that you would like to discuss?
Yes
No
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61
If yes, please provide details below
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