Global Health Services
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MEDICAL HISTORY QUESTIONNAIRE
GENERAL INFORMATION
First Name Sex Male Female
Last Name
Occupation
Employer's name
Address
Tel(Home) Postal code
Tel(Mobile) Tel(Work)
Birthdate(d/m/y) Email
Hand Dominance Right Left Age
Sleep Position
Sleep Quality Good Mod Bad
PRESENT HISTORY
Are you followed by a Doctor? Name
Are you followed by a Physiotherapist? Name
If yes, for what condition?
Do you take medication?
If yes, which?
PAST MEDICAL HISTORY
Allergies Osteo-Arthritis
Circulation Tendinitis
Muscular Bursitis
Respiratory Fibromyalgia
Digestive System Ostieoporosis
Nervous System Asthama
Arthritis Pregnancy
#Month
Further notes
Stress Level High      Medium      Low      Normal