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PATIENT QUESTIONNAIRE
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Name
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Address
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Province/Postal code
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Phone
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E-mail
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Age
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Marital status
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Occupation
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Children (number, age)
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Today's date
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Which is your main health problem?
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Do you suffer presently from other diseases or symptoms?
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What kind of diseases, operations, injures and accidents have you had in your life?
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Are there any diseases and disturbances in your family?
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Are there any stress factors or burdens in your social environment?
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Are you on medication at present ? Please, list them
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Weight
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Height
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Blood pressure
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Sleep Disturbances (yes, no)
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Heart + Breathing problems (yes, no)
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Disturbances of bladder or genitals (yes, no)
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Allergies (yes, no)
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Psychological problems (yes, no)
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Are you vegetarian? (yes, no)
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Do you smoke? (yes, no)
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Do you have a physical disability (yes, no)
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Alcohol consumption per day
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Which doctors are you seeing presently?
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How did you learn about our service?
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