Medical/health Status Questionnaire
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4Medical/Health Status Questionnaire
On this questionnaire, a number of questions regarding your physical health are to be answered. Please
answer every question as accurately as possible so that a correct assessment can be made. Please
place a check in the space to the left of the question to answer "Yes." Leave blank if your answer is "No."
Please ask if you have any questions. Your responses will be treated in a confidential manner.
Today's Date:
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Your Name:
Medical Screening
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Do you have any personal history of heart disease (coronary or atherosclerotic disease)?
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Any personal history of diabetes or other metabolic disease (thyroid,renal,liver)?
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Any personal history of pulmonary disease, asthma, interstitial lung disease or cystic fibrosis?
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Have you experienced pain or discomfort in your chest apparently due to blood flow deficiency?
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Any unaccustomed shortness of breath (perhaps during light exercise)?
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Have you had any problems with dizziness or fainting?
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Do you have difficulty breathing while standing or sudden breathing problems at night?
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Have you experienced a rapid throbbing or fluttering of the heart?
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Do you suffer from ankle edema (swelling of the ankles)?
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Have you experienced severe pain in leg muscles during walking?
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Do you have a known heart murmur?
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Has your serum cholesterol been measured at greater than 200 mg/dl?
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Are you a cigarette smoker?
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Has your HDL (the "good" cholesterol) been measured at greater than 60 mg/dl?
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Would you characterise your lifestyle as "sedentary"?
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Have you had a high fasting blood glucose level on 2 or more occasions (>=110mg/dl)?
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Are you 20% or more overweight or have you been told your “BMI” was greater than 30?
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Have you been assessed as hypertensive on at least 2 occasions (systolic > 140 mmHg or
diastolic > 90mmHg)?
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Do you have any family history of cardiac or pulmonary disease prior to age 55?
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Parent category: Life