Screening Questionnaire

Please fill in this form which will give us the facts we need to start you on the pathway to good health.

We will, of course, exercise the strictest confidence with all the information you provide.

Name

Mobile Number

Address

Post Code

Date of Birth

Age

Occupation

Number/Age of Children

Doctor's Address

Which particular health problem do you wish to overcome?

How did you hear about Health for Wealth?

Please tick your symptoms: Occasionally (every six months) or Often (more than once a month)

General

Headache (occasionally) Headache (often) Migraines (occasionally) Migraines (often) Fever/chills (occasionally) Fever/chills (often) Fainting (occasionally) Fainting (often) Dizziness (occasionally) Dizziness (often) Convulsions (occasionally) Convulsions (often) Loss of sleep (occasionally) Loss of sleep (often) Fatigue (occasionally) Fatigue (often) Nervousness/Anxiety (occasionally) Nervousness/Anxiety (often) Weight loss/gain (occasionally) Weight loss/gain (often) Inability to lose weight (occasionally) Inability to lose weight (often) Any allergies (occasionally) Any allergies (often) Thrush/Cystitus (occasionally) Thrush/Cystitus (often) Thirst (occasionally) Thirst (often)

Ear, Nose & Throat

Failing vision (occasionally) Failing vision (often) Deafness (occasionally) Deafness (often) Earache (occasionally) Earache (often) Ear noises/discharges (occasionally) Ear noises/discharges (often) Nose bleeds (occasionally) Nose bleeds (often) Sore throat/hoarseness (occasionally) Sore throat/hoarseness (often) Asthma/wheezing (occasionally) Asthma/wheezing (often) Gum trouble (occasionally) Gum trouble (often) Frequent colds (occasionally) Frequent colds (often) Thyroid disorder (occasionally) Thyroid disorder (often) Tonsilitis (occasionally) Tonsilitis (often) Sinus infection (occasionally) Sinus infection (often) Nasal drainage problems (occasionally) Nasal drainage problems (often) Enlarged glads (occasionally) Enlarged glads (often) Hayfever (occasionally) Hayfever (often) Chronic cough (occasionally) Chronic cough (often) Spitting up phlegm (occasionally) Spitting up phlegm (often) Spitting up blood (occasionally) Spitting up blood (often)

Skin

Skin eruptions/acne (occasionally) Skin eruptions/acne (often) Itching (occasionally) Itching (often) Bruise easily (occasionally) Bruise easily (often) Dryness (occasionally) Dryness (often) Boils (occasionally) Boils (often) Varicose veins/DVT (occasionally) Varicose veins/DVT (often) Sensitive skin/hives (occasionally) Sensitive skin/hives (often) Eczema (occasionally) Eczema (often) Psoriasis (occasionally) Psoriasis (often)

Cardio-vascular

Chest pain (occasionally) Chest pain (often) Slow/rapid heartbeat (occasionally) Slow/rapid heartbeat (often) Low/high blood pressure (occasionally) Low/high blood pressure (often) Previous heart attack (occasionally) Previous heart attack (often) Hardening of arteries (occasionally) Hardening of arteries (often) Swelling of ankles (occasionally) Swelling of ankles (often) Cold extremities (occasionally) Cold extremities (often) Paralytic stroke (occasionally) Paralytic stroke (often) Blood clots (occasionally) Blood clots (often) High cholesterol (occasionally) High cholesterol (often)

Muscles & Joints

Stiff neck (occasionally) Stiff neck (often) Backache (occasionally) Backache (often) Shoulder trouble (occasionally) Shoulder trouble (often) Painful elbow/wrist/hands (occasionally) Painful elbow/wrist/hands (often) Fibromyalgia (occasionally) Fibromyalgia (often) Jaw joint trouble (occasionally) Jaw joint trouble (often) Knee problems (occasionally) Knee problems (often) Hip joint problems (occasionally) Hip joint problems (often) Swollen/painful joints (occasionally) Swollen/painful joints (often) Tremors (occasionally) Tremors (often) Painful tail bone (occasionally) Painful tail bone (often) Foot trouble (occasionally) Foot trouble (often) Sciatica (occasionally) Sciatica (often) Numbness in limbs (occasionally) Numbness in limbs (often) Neuralgia (occasionally) Neuralgia (often)

Genito-urinary

Frequent urination (occasionally) Frequent urination (often) Painful urination (occasionally) Painful urination (often) Blood in urine (occasionally) Blood in urine (often) Kidney infection or stones (occasionally) Kidney infection or stones (often) Bed wetting (occasionally) Bed wetting (often) Inability to control urine (occasionally) Inability to control urine (often) Prostate trouble (occasionally) Prostate trouble (often)

Gastro-intestinal

Poor appetite (occasionally) Poor appetite (often) Excessive hunger (occasionally) Excessive hunger (often) Difficult digestion (occasionally) Difficult digestion (often) Belching or gas (occasionally) Belching or gas (often) Nausea (occasionally) Nausea (often) Vomiting (occasionally) Vomiting (often) Heartburn/indigestion (occasionally) Heartburn/indigestion (often) Vomiting blood (occasionally) Vomiting blood (often) Pain over stomach (occasionally) Pain over stomach (often) Abdomen distension (occasionally) Abdomen distension (often) Constipation (occasionally) Constipation (often) Diarrhoea (occasionally) Diarrhoea (often) Colon trouble (occasionally) Colon trouble (often) Haemorrhoids (piles) (occasionally) Haemorrhoids (piles) (often) Intestinal worms (occasionally) Intestinal worms (often) Liver trouble (occasionally) Liver trouble (often) Gall bladder trouble (occasionally) Gall bladder trouble (often) Jaundice (occasionally) Jaundice (often) Colitis/Crohns disease (occasionally) Jaundice (often) Coeliac (occasionally) Coeliac (often) IBS diagnosis (occasionally) IBS diagnosis (often)

Women only (tick if yes)

Breast implants? Painful menstrual problems Excessive flow Hot flushes Irregular cycle Cramps or backache Do you still have periods? Previous miscarriage Vaginal discharge Lumps in breast Menstrual problems PMT

If you have had any of the following diseases, please tick

Pneumonia Rheumatic fever Pleurisy Tuberculosis (TB) Alcoholism Arthritis Herpes Venereal disease Epilepsy Eating disorder Depression / Bipolar Gastric ulcers Anaemia Hepatitis Glandular fever Diabetes Aids Thyroid (hypo/hyper) Cancer Heart disease Other

If you have had any of the following operations, please tick and give approximate dates below

Gall bladder Appendix Hernia Tonsilectomy Hysterectomy Mastectomy Lumbar punctures Major dental work, including: Root canal/implants/llings Spinal fusion / Laminectomy Caesarean section Other (please specify below)

Please list other operation details and dates of operations here:

Please tick any of these examinations you have had in the past five years

Spinal X-rays Barium meal X-rays Other X-rays inc dental Urinalysis Brain scan Body scan ECG Mammogram Blood tests Others (please specify below)

Please list other examination details here:

Do you smoke?

How many per day?

Recreational drugs? (Past/Present)

How many glasses of wine/pints per week?

Undertake physical excerise?

Please list medications here:

Have you ever broken any bones?

How and when?

Have you ever had any bad falls or been involved in any accident?

Give brief details and dates

Is there anything else we should know? Any specific diagnosis given?

Signature

Date

Screening Questionnaire

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