Medical History Questionnaire?? Please help!!

[Katria 0]

:thumbup: Please help me fill out the medical history questionnaire.. I have no idea what to put or what they want me to write.

1. Musculoskeletal (Bone/Muscles) system review Bursitis

Tendonitis

Arthritis or swollen joints

Back problems

Sciatica

Necl pain

Muscle or extremity weakness

Morning stiffness

Jaw pain, popping or clicking

X rays

2. Please comment on above question (14) answers.

3. Metabolic system review Diabetes mellitus

Gestational diabetes

Thyroid problems or disorder

Are you on or have been on thyroid replacement medications?

Elevated cholesterol or triglycerides

4. Do you have any of the following ? Rheumatic Fever

Pneumonia

COPD

Pleurisy or other lung disease such as sarcodosis

Pulmonary Artery Hypertension

High Blood pressure

Heart Attack

Diabetes Mellitus

GERD

Esophagitis

Gastric Ulceration

Duodenal ulceration

Helicobactor pylori infection

Upper Gastrointestinal bleeding, bleeding ulcer

Esophageal or Gastric Varices

Congenital or acquired intestinal telangiectases (Sturge Weber Syndrome)

Crohn's Disease

Atresia's or Stenosis of the GI tract

Cirrhosis

acute or Chronic Pancreatitis

Anemia

Bleeding Tendencies

Psoriasis

Cataracts

Radiation Treatement

Thyroid dsease

Accidents or major trauma

Other hospitalizations

Addiction to alcohol or drugs (must be clean and sober 5 yrs with proof)

Bi-polar disorder (patients have to document compliance with medication and follow up)

Have you ever been diagnosed with a connective tissue disease, such as Lupus, Scleroderma, or Sicca syndrome? Anyone in your immediate family?

Are you on large doses of Steroids?

Other illneses

5. Please comment on above question (20) answers

6. Systems Review General Weight loss or Gain

Chills

Fever

Night Sweats

Weakness

Easy fatigability

Intolerance to Cold or Heat

7. Please comment on the above question (6) answers.

8. Please comment on above question (12) answers.

9. Respiratory (Lungs) Shortness of Breath

Cough up blood

Pleurisy

Chronic Cough

Asthma

Abnormal Chest Xray

Last Chest X ray

10. Psychiatric Depression

Bipolar disorder

Anxiety (nervousness)

Suicide thoughts or attempts

Psychiatric trreatment

Counseling

11. Genitourinary (kidneys) system review Get up at night to urinate

Kidney or Bladder infections

Difficulty with Urination

Blood in Urine

Kidney Stones

Surgery

Prostate Problems

Kidney xrays or ultrasounds

12. Plese comment on above question (18) answers

13. Please comment on the above question (4) answers.

14. Please use this area to tell us about any of the diagnoses, hospitalizaations, or other major illness you might have in the 1st question.

15. Please comment on above question (24) answers

16. HEENT System Review Headaches

Sudden vision changes

Glaucoma

Dry eyes

Do you wear glasses or contacts

Have you had any eye surgery such as LASIK or LASEK or RK

If Diabetic, when was your last retinal eye exam?

Ear infections

Vertigo

Nose Bleeds

Allergies

Sinusitis

Dentures Bridges

Mouth ulcers

Hoarseness

Dry mouth

SICCA syndrome

17. GI system review Difficulty swallowing

food getting stuck

Indigestion

Change in Bowel Habits

Blood in stool

Dark or tar colored stools

Surgery

Vomiting

Nausea

Diarrhea

Constipation

Irritable Bowel Syndrome

Pain

Vomiting Blood

Jaundice

Gallbladder problems

Pancreatitis

Stomach Xray

Colon Xray

Gallbladder Ultrasound

EGD or colonoscopy

18. Please comment on above question (16) answers

19. Please Comment on above question (10) answers

20. Neurological (Brain/Nerves) system review Dizziness

Fainting or Blackouts

Irritability

Seizures (epilepsy)

Numbness

Peripheral neuropathy (nerve damage)

Spasm

Xrays

Nerve conduction studies

21. GYN History for Women Age at Menarche: Age first preganancy: Age at Menopause: Last mensturual period: Number of Pregnancies: Miscarrages, abortions?" Eclampsia or premature delivery? Number of living children: Did you breast feed?

22. Please comment on above question (22) answers

23. Heart System Review Chest pain or discomfort

High Blood pressure

Heart Murmur

Palpitations or Fluttering

Edema(swelling of feet)

Myocardial infarction (heart attack)

Pacemaker

Coronary angiogram

Angioplasty or Stent placement

Recent Stress test or cardiac evaluation for chest pain

24. Pease comment on the above question (8) answers.

25. Skin Review Ulcers or Nodules

Rash

Easy Brusining

Unusal change in Body hair

Skin Cancer

Recent Change in a mole

Color Chnage in fingers

Tightness

[kgloverii 0]

They are basically looking for a complete health history. If you've had these conditions, be upfront and honest about them. This will allow the doctors to help educate you as you go along on your journey about your diet, things you may have to give up, things you might need to incorporate, etc. This will also allow you to see down the road, if any of your conditions have cleared up as a result of your weight loss. For instance, I no longer get migraines!