Medical History Questionnaire Medical History Questionnaire Current Medications: Allergies Other (known) medical problems – Please tick Diabetes Kidney Disease Hypertension arthritis Asthma/COPD Heart problems Stroke Hepatitis Other Other Previous operations Smoking Status: Current Former Never Alcohol intake: Current symptoms: Pain Breathing difficulty Poor food intake Weight Loss Fatigue Constipation Diarrhoea Depression Anxiety Memory Sexual Other Other Daily activities: Please circle the number (0-10) that best describes how much active you are during the daytime 0 1 2 3 4 5 6 7 8 9 10
