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General health questionnaire

We kindly ask you to fill out this list. It consists of 45 questions of which the majority can be answered with a yes or no. It will take approximately 5 minutes to complete the form. Your answers will be treated with the up most confidentiality.
Thank you.

Personalia
General health questionnaire

1. Has anything changed to your health, in the last couple of months?

What has changed?

2. Are you being treated by a medical specialist?

What for?

3. In the last couple of years, have you been admitted to a hospital?

What for?

4. Have you ever had a lifethreathning disease?

Which disease?

5. Are you allergic to anything?

For what?

6. Have you ever had a heartattack?

When?

7. Have you ever had palpilations?

8. Are you being treated for high bloodpressure?

What is your pressure usually?

9. Do you ever have pain to the chest when you're emotional or exercising?

10. Do you ever have swollen ankels or feet?

11. Are you ever short of breath when you lie down?

12. When exercising, do you ever get short of breath?

13. Do you have a valvularproblem or a artificial heart valve?

14. Do you have a congenital heart defect?

15. Do you have a pacemaker (or ICD)?

16. Are you in the care of the trombosisservice?

17. Have you ever fainted during a dental or medical treatment?

18. Do you ever suffer from hyperventilation?

19. Do you have epilepsy?

20. Have you ever had a cerebral hemorrhage or stroke?

21. Do you have respitoryproblems like asthma, bronchitis or chronic cough?

Are you short of breath as well?

22. Are you diabetic?

Do you use insuline?

23. Are you anemic?

24. Have you ever had longterm bleeds, after pulling a tooth or after an operation?

25. Do you have (or ever had) hepititas, jaundice or any other liver disease?

26. Do you have a kidneydisease?

27. Do you have chronical bowelproblems?

28. Do you have a condition of the thyroid?

29. Are you reumatic and/or do you have chronic jointproblems??

30. Do you have a contagious disease?

Which one?

31. Do you suffer from depression?

32. Have you visited a psychologist or psychiatrist, in the last couple of years?

33. Have you ever received radiotion treatment for a tumor to your head or neck?

34. Do you smoke?

How often a day?

35. Do you consume alcohol?

How often a week?

36. Have you, or do you ever use drugs?

Which drugs?

37. If you are a woman, are you pregant?

What is your due date?

38. Do you have a condition or disease not listed above?

Which condition or disease?

39. Do you currently use medication?

What do you use?

Who is your general practitioner? In case you don't have permanent general practitioner, please fill in: 'none'.

I confirm that I have completed the form truthfully.

Because of the GDPR law, we need your consent to process and store your personal data and in our system.

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