Consent And Release For Screening Page 2
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1
2
3CONSENT AND RELEASE FOR SCREENING
This form
must be completed
before your screening
Page 2/3
Your Health History
Please answer the following with regard to your health:
Have you every had a health screening before?
YES
NO
If ‘YES’ when and who with?
Do you know your own blood group?
YES
NO
Do you have a history of diabetes? Type 1 / Type 2
YES
NO
Do you have a history of high blood pressure (hypertension)?
YES
NO
Do you have a history of high cholesterol?
YES
NO
Do you have a history of heart disease?
YES
NO
Do you have a history of anaemia or iron overload (hemochromatosis)?
YES
NO
Do you have a history of osteoporosis?
YES
NO
Do you have a history of thyroid problems (over-active / underactive)?
YES
NO
Have you ever been diagnosed with stomach ulcers (Peptic or Duodenal)?
YES
NO
Have you ever been diagnosed with Helicobacter pylori (H. pylori)?
YES
NO
Do you currently experience any of the following on a regular basis? (please underline)
Heartburn, indigestion, bloating, regurgitation, reflux, abdominal pain, constipation, diarrhea, nausea, vomiting,
YES
NO
flatulence, irritable bowel syndrome (IBS)?
If ‘YES’, how often?
Are you taking any medication?
YES
NO
If ‘YES’ please list:
Do you have any known allergies?
YES
NO
If ‘YES’ please list:
Do you have any other illness history or concerns not listed above?
If ‘YES’, please explain:
YES
NO
MEN ONLY
Do you regularly experience any of the following symptoms?
Weak or reduced urine flow, frequent urination, poor emptying, Hesitancy in starting to urinate, urine
YES
NO
dribble, painful urination, painful ejaculation, testicular pain, difficulty getting or maintaining an erection,
new or unexplained pain in the lower back, hips or pelvis, blood in the urine or semen?
Do you have a history of prostate problems?
YES
NO
Do you have a family history of prostate problems?
YES
NO
Have you ever had a PSA Test (prostate blood test)?
YES
NO
WOMEN ONLY
Are you or could you be pregnant?
YES
NO
Have you started Menopause? Age of Commencement?
YES
NO
Do you have family history of breast cancer?
YES
NO
| keeping you on your perch!
Screenetics UK Limited, Registered in England No. 06151366.
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