""
1
SECONDARY SCHOOL AGE CHILD MEDICAL HEALTH FORM (13 years and above)
Please ensure you have completed a Patient Contact Details Form prior to completing this Medical History Form.
Nameyour full name
Date of Birthdd/mm/yyy
Please provide a brief description of your problem?max 300 characters
0 /
Do you know what caused your problem?max 300 characters
0 /
Is the problem improving?max 300 characters
0 /
Are your symptoms worse during the day or at night?
At the onset of your problem, did you experience any trauma, illness/infection or other significant event?
0 /
Does your pain wake you at night?
Describe what aggravates/relieves your problem?
0 /
Have you had any other treatment for your current problem?optional
0 /
Who was the practitioner?optional
0 /
Did you find the treatment effective?pick one!
Please rate the severity of your symptoms10 being the most severe pain (drag button)
0
010
Does your current problem involve any of the following:
Yes No
Pain in either arm and leg
Tingling in either arm and leg
Numbness in either arm and leg
Weakness in either arm and leg
"Weird" sensations in either arm and leg
Please indicate yes/no to the following:
Yes No
Do you think you have a healthy diet?
Do you take vitamin supplements?
Do you exercise regularly?
Please list any sports/hobbies you have
0 /
Please comment on any signicant surgery and hospitalisation
0 /
Are you currently taking any form of medication? If Yes please list medications.
0 /
Do you have any other significant medical history?Eg. Cancer, Diabetes, Heart Disease,/Hypertension, Asthma, Fractures, Sports Injuries, Falls
0 /
Have you ever had a car accident? If Yes please describe?No matter how trivial please describe details
0 /
Please indicate yes/no to the following
Yes No
Do you have frequent headaches?
Do you feel stressed?
Have you experienced dizziness/vertigo/faints/blackouts?
Do you suffer from fatigue?
Do you suffer from night sweats/fever?
Do your joints swell?
Have you lost/gained weight in the past year?
Do you have digestive problems?
Have you noticed any blood or mucus in your bowel movements?
Do you suffer from shortness of breath or chest pain on exertion?
Do you have any pain or increased frequency on passing urine?
Do you have any unusual lumps/swelling on your body?
Do you have any problems with hearing? (Including ringing in ears)
Do you have any problems with smell or taste?
Are you easily depressed?
Do you suffer from anxiety?
Do you have poor sleep?
Do you have any problems with your vision?
Do you have poor balance?
I consent for my information to be communicated to my GP and/or other relevant health professionals when appropriate.pick one!
Previous
Next