MEDICAL INFORMATION FORM.

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INTRODUCTION

For a quality health standard services, including tele-medicine, it is required that our users give us precise information about their health and medical status and regularly update their information in order to provide them with excellent and effective health and medical services.

In order to do this, we ask you to provide details of your health. We will contact you if we need further details and, if necessary, ask for a report from your medical or dental provider. The health of each user is considered individually, even if a family medical history or a professional exposure could be of guidance to understand the logic behind your health status.

Please answer ALL the following Ten (10) group of questions by organic systems. If you answer YES to health issues in any organ system, you will need to give further details answer to all the under-questions in the group in addition to open text for other potential health issues not specified in the questionnaire. If you have any questions, contact our support for advice. You are asked to indicate whether you currently have or have ever had any of the following medical conditions organized by systems and organs.

If you have ticked Yes to any of the questions, please give details in the space provided in every paragraph. This will help the Health Unit to clarify the significance or otherwise of a Yes answer. Please ensure that you quote the correct question and medical condition with the paragraph letter and the point number. For details of any Medical Condition, please include date(s) of illness/conditions, frequency, duration, what treatment was given and by whom (e.g., hospital / GP), whether you are still undergoing treatment and length of absence from work / school (if appropriate). Family History (parents or sibling

Please note that you will be required to sign a declaration at the end of this questionnaire. It is important that your answers are accurate and you do not withhold any information.
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PART A: LIFESTYLE AND GENERAL HEALTH RELATED PROBLEMS

General Lifestyle and known Health Problems
Please answer the questions below with Yes or No
# Question Yes No
1 Have you experienced any abnormal weight gain or loss (more than 20 kg) over the last 6 months?
2 Do you smoked more than 20 cigarettes (average) a day over the last year?
3 Do you drink more than 20 glasses (average) of alcohol (beer/wine/whisky etc.) in a week?
4 Have you ever taken drugs, narcotics, sniffed glue or been treated for drug addiction?
5 Have you ever been diagnosed with HIV or Hepatitis A – B or C?
6 Has any of your parents/siblings suffered from cancer, stroke, heart, liver or kidney disease?
7 Are you currently suffering from; Diabetes, Hypertension or Hyperlipidaemia?
8 Do you have any diabetic related complications such as amputation, kidney failure, coma, etc.?
9 Do you have dental issues involving your teeth, gums or cavities?
10 Do you wear any type of dentures (PUSTISO) removable or fixed?
11 Your Height? cm/inch
12 Your Weight? lbs/kg
# Question Yes No
13 Are you taking medications regularly?
14 Are you currently attending a hospital/GP for treatment or waiting for an appointment?
If YES to any question or if any other General Health issues? Please Explain.
Please list below any of your Current prescribed medication including: tablets, capsules, injections, inhalers and creams including birth control? Please specify:
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PART B: CARDIO-VASCULAR SYSTEM RELATED HEALTH PROBLEMS

Do you have any Cardio-Vascular System Health Problems?
Yes
No
Please answer the questions below with Yes or No
# Question Yes No
1 Chest pain
2 Angina
3 Heart Disease
4 Palpitations
5 Breathlessness
6 Varicose veins
7 Ankle swelling
8 Circulation problem
9 Rheumatic fever
10 Any blood disorder
11 Are using a pacemaker
12 Hypertension or Low blood pressure
If YES to any question or if any other Cardio-Vascular illness? Please Explain.
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PART C: RESPIRATORY SYSTEM RELATED HEALTH PROBLEMS

Do you have any Respiratory System Health Problems?
Yes
No
Please answer the questions below with Yes or No
# Question Yes No
1 Asthma
2 Bronchitis
3 Pneumonia
4 Emphysema
5 Pleurisy
6 Pneumothorax
7 Tuberculosis
8 Cough
9 Hemoptysia
10 Epistaxis
11 Difficulty Breathing
12 Are you using Oxygen tank?
If YES to any question or if any other Lung or Respiratory disease? Please explain
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PART D: GASTRO-INTESTINAL SYSTEM RELATED HEALTH PROBLEMS

PART D: GASTRO-INTESTINAL SYSTEM RELATED HEALTH PROBLEMS
Do you have any Oral or Gastro-Intestinal System Health Problems?
Yes
No
Please answer the questions below with Yes or No
# Question Yes No
1 Do you have Recurrent Dental, oral, Nausea, Dyspepsia or Dysphagia?
2 Do you have Recurrent Heartburn, Indigestion or Hiatus Hernia?
3 Gastric, Duodenal or Peptic ulcer?
4 Do you have Abdominal pain?
5 Diarrhea or Vomiting lasting more than one week?
6 Do you have any abdominal Hernia?
7 Gastro-intestinal or Rectal bleedings?
8 Irritable Bowel Syndromes?
9 Crohn’s Disease?
10 Ulcerative Colitis?
11 Jaundice or Problems with Gallbladder?
12 Any form of hepatitis or other liver problem?
If you answer YES or if you have any other Oral, Dental or abdominal complaint? Please explain
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PART E: AUTO-IMMUNE METABOLIC AND ENDOCRINE SYSTEMS RELATED HEALTH PROBLEMS

Do you have any Metabolic and Endocrine System Health Problems?
Yes
No
Please answer the questions below with Yes or No
# Question Yes No
1 Any weight or appetite changes
2 Do you have Diabetes
3 Any Thyroid Disfunction
4 Any Adrenal Gland Disease
5 Do you have any auto-Immune illness related problems?
If you answer Yes or if you have Any other metabolic problems or other glandular disorder you are aware off ? Please explain.
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PART F: SKIN RELATED HEALTH PROBLEMS

PART F: SKIN RELATED HEALTH PROBLEMS
Do you have any Metabolic and Endocrine System Health Problems?
Yes
No
Please answer the questions below with Yes or No
# Question Yes No
1 Do you have any allergies or Urticaria?
2 Do you have Psoriasis?
3 Do you Have Eczema?
4 Do you have Allergic dermatitis?
5 Do you have any skin infections?
6 Do you have vetiligo?
7 Do you have tendency to skin cancer?
8 Do you have allopecia?
If you answer YES or if you have any other Oral, Dental or abdominal complaint? Please explain
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PART G: MUSCULOSKELETAL SYSTEM RELATED HEALTH PROBLEMS

Do you have any Musculoskeletal System Health Problems?
Yes
No
Please answer the questions below with Yes or No
# Question Yes No
1 Do you have bones or joints pain, dislocation or swelling? If yes please indicate below.
2 Neck
3 Back
4 Shoulder
5 Elbow
6 Handled
7 Hip
8 Knee
9 Ankle
10 Have you been diagnosed as having arthritis, gout, or rheumatism?
11 Do you have Sciatica?
12 Do you have Osteoporosis or recurrent fractures?
If your answer is Yes to any question or if you have ever consulted an orthopedic surgeon, osteopath, Chiropractic, or physiotherapist? Please elaborate.
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PART H: NERVOUS SYSTEM RELATED HEALTH PROBLEM

Do you have any Psychology-Nervous System Health Problems?
Yes
No
Please answer the questions below with Yes or No
# Question Yes No
1 Do you have headaches, migraines, vertigo, dizziness, giddiness or problems with balance?
2 Do you have any diseases of the nervous system like, neuritis, stroke or multiple sclerosis?
3 Did you had any Head injuries leading to loss of consciousness requiring hospital admission?
4 Do you have Epilepsy, fits, blackouts, fainting turns or unexplained loss of consciousness?
5 Do you have any limb motor or sensory symptoms or loss of coordination?
6 Do you have any visual defect e.g., scotoma, blindness in one eye, night blindness, blindness, color blindness, reduced visual field, blurred vision or detached retina?
7 Do you have any eye disease or conditions such as glaucoma or retina issues?
8 Did you had any Injury or surgery to your eye(s) including laser eye surgery?
9 Do you have or had any Ear infection, discharge, tinnitus, a hearing defect including deafness?
10 Do you have issues with Speech and related functions like reading and writing skills and memory?
11 Do you have any defect in your testing and smelling abilities?
If you answer YES for any question or if you ever consulted an Otolaryngologist, Ophthalmologist.
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PART I: PSYCHOLOGY AND MENTAL HEALTH PROBLEMS

Do you have any Psychological or Mental Problems?
Yes
No
Please answer the questions below with Yes or No
# Question Yes No
1 Do you have Anxiety/Depression, phobias, mental breakdown or stress related problems?
2 Do you have any Mental Illness and / or cognitive disorders, such as: Alzheimer or Dementia?
3 Do you have any disorders affecting learning, memory, perception and problem solving?
4 Do you have any eating disorder e.g., anorexia nervosa or bulimia?
5 Do you suffer from Substance misuse?
6 Do you have sleeping disorder?
If YES to any question or if any other Lung or Respiratory disease? Please explain.
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PART J: GENITO-URINARY SYSTEM RELATED HEALTH PROBLEMS

Do you have any urinary System Health Problems?
Yes
No
Please answer the questions below with Yes or No
# Question Yes No
1 Frequency in urination
2 Pain with micturition
3 Urethral Discharge
4 Blood or change of urine color
5 Kidney stones
6 Urgency in Urination
7 Incontinence
8 Recurrent kidney or urinary tract infection
9 Cystitis
10 Urethritis
Any other kidney or bladder conditions or complaint? Please explain
NOTE: THAT IF THE USER GENDER IS SELECTED, THE USER WILL AUTOMATICALLY GO TO THE QUESTION ACCORDING TO THEIR GENDER.
Genitalia MEN:
Do you have any urinary System Health Problems?
Yes
No
Please answer the questions below with Yes or No
# Question Yes No
11 Any issues with the Prostate?
12 Any testicular issues?
13 Any actual or previous sexually transmitted infection?
14 Any sexuality issues, problems with erection etc.?
If YES or if any other genitalia or sexuality issues you are aware of? Please explain
Genitalia WOMEN:
Do you have any urinary System Health Problems?
Yes
No
Please answer the questions below with Yes or No
# Question Yes No
11 Any problem with the menstruation?
12 Are you in Menopause phase?
13 Are you aware of, any breast lumps or disorder?
14 Any family members been diagnosed with breast cancer?
15 Are you aware of any disorder with ovaria or uterus: fibroid, cyste, polyps?
16 Any abnormal pap smear test?
17 Any complications during any of your pregnancies such as gestational?
If YES or if any other genitalia or sexuality issues you are aware of? Please explain
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