Medical Questionnaire Form Page 2
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1
2
3Name:
Date:
High Cholesterol (abnormal lipids)
Yes
No
Heart Disease or Previous Heart Attack
Yes
No
Asthma
Yes
No
Arthritis
Yes
No
Back Pain
Yes
No
Legs ulcer or Reddish-brown legs
Yes
No
Depression
Yes
No
COPD (Chronic Obstructive Pulmonary
Yes
No
Disease)
Severe symptoms:
Yes
No
History of hospitalization due to COPD:
Yes
No
Pulmonary Embolism (blood clot in lungs)
Yes
No
DVT (blood clot in legs)
Yes
No
Stroke
Yes
No
Gallstones/ Gallbladder disorder
Yes
No
Polycystic Ovarian Syndrome
Yes
No
Bleeding disorder
Yes
No
Liver disorder
Yes
No
Kidney disorder
Yes
No
Thyroid disorder
Yes
No
Seizure
Yes
No
Use of scooter, wheelchair, or other device
Yes
No
to move around
Activities of daily living
Independent
Dependent (Total or Partial)
Requiring oxygen:
Yes
No
Obstructive Sleep Apnea
Yes
No
Sleep study done:
Yes
No
CPAP required:
Yes
No
High Risk of Sleep Apnea (STOP-Bang Score)
1.
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
Yes
No
2.
Do you often feel tired, fatigued, or sleepy during daytime?
Yes
No
3.
Has anyone observed you stop breathing during your sleep?
Yes
No
4.
Do you have or are you being treated for high blood pressure?
Yes
No
Any Other Medical History- Please list ALL other medical history
FAMILY HISTORY – Please mark “x” to all that apply
High Blood
High
Family member
Obesity
Diabetes
Heart disease
Cancer (indicate type)
Pressure
Cholesterol
Father
Mother
Grand parents
Do you or any of your family members have a history of a bleeding or clotting disorder? Yes / No
Please list: ___________________________________________________________________________________________
Weight Loss History
How long have you been at your present weight? ______________ yrs
What did you weigh 5 years ago? _____________lbs
What is the most you have ever weighed in your adult life? ____________ lbs The least weight? ___________lbs
Page 2 of 3
Version date: April 10, 2014
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Parent category: Life