Medical History Questionnaire

Medical History Questionnaire

In order to prepare for the consultation, I would like to have a fuller idea of your medical history and exposures to potential health hazards. Please answer the questions as best you can. Be assured that everything you submit is for my eyes only and will not be shared with third parties.

Dr. Indunil Weerarathne

EmailPhone Number
Skype ID:
Full Name:
Date of Birth (MM/DD/YYYY):
Time of Birth (AM/PM):
Place of Birth:
Gender:
Height (cm):
Weight (kg)
Please list all the difficulties and discomforts related to your medical conditions
How and when did the present symptoms start? (Please list how each medical problem started, if you remember)
What are the other medical conditions from which you suffer?
Do you have a history of the following surgical procedures?

Do you have a family history related to these conditions?
Do you have a history of any of the following? Please mark all the relevant answers.

Do you have a history of use of pharmaceuticals? If so, please list the prescriptions medications as well as any over-the-counter medicines and supplements you have been taking?
Do you have a history of vaccinations? Please list.
How many amalgam fillings do you have?
If the above answer is yes, using the chart below, please mark the tooth/ teeth from the chart below.
tooth_numbers
At what age the amalgam fillings were done?
If you previously had amalgam (silver) dental fillings and they were removed, did you go through a process of toxic metal chelation afterwards?
How many composite fillings do you have?
At what age the composite fillings were done?
If the above answer is yes, using the chart below, please mark the tooth/ teeth from the chart below.
tooth_numbers
Any history of food poisoning or food allergies?
Any history of other allergies?
What’s your occupation? How would you rate the stress level of your job?
Can you describe your diet?
Are you careful to eat organically?
Do you/ have you ever used a microwave oven?

What is the source of your drinking water?

How is your appetite and digestion?
How many times per day do you have a bowel movement?
How would you describe the form of the stool? (Please mark all the relevant answers)

How many times per day do you urinate?
How would you describe about your urine? Please mark all the relevant answers.

Please describe about your menstruation? Please mark all the relevant answers.

How many biological children do you have?
Were the deliveries normal?

Do you have a history of contraceptive use?

Do you/ have you ever consumed alcohol? If yes, how many glasses per week?
Do you/ have you ever smoked? If yes, how many cigarettes per day?
Do you have a history of psychedelic drug use? Please list the names of the drugs and the duration of use.
Are/ were there any problems that disturb you psychologically?

Please describe your sleep.

How would you describe your relationship to other family members? E.g. husband/ wife/ children/ parents/ siblings, etc.
How do you feel about your life? What are your responsibilities, duties, inspirations and aspirations, etc.?

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