MEDICAL INFORMATION FORM.

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PART:A LIFESTYLE AND GENERAL HEALTH EVALUATION

Vital Signs & General Health Evaluation
Normal Abnormal
1 General Appearance
2 General Mobility
3 General Coherence
4 Responsiveness to questions
cm inch
5 Height
lbs kg
6 Weight
7 Respiratory Rate
8 Blood Pressure
9 Heart Rate
10 Temperature
11 Body Build
12 BMI: -- %
If any finding or sign of abnormalities related to General Health Examination?
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PART:B LIFESTYLE AND GENERAL HEALTH EVALUATION

General Results of Cardio-Vascular System Examination?

Vital Signs & General Health Evaluation
Normal Abnormal
1 Heart Auscultation
2 Valves evaluation
3 Rhythm Regularity
4 Any Circulation problem
5 Arterial Check Pulses
6 Varicose veins?
7 Ankle swellings?
8 Puls
9 BP
10 Signs of bleadings?
11 Pacemaker user?
12 Other findings?
If any finding or sign of abnormalities related to Cardio-vascular examination ?
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PART:C RESPIRATORY SYSTEM EXAMINATION

General results of Lung and Respiratory System Examination?
IF ANY ABNORMAL FINDINGS PLEASE SPECIFY IN ALL THE FOLOWING AREAS
Normal Abnormal
1 Auscultation of lungs results
2 Signs of Bronchitis?
3 Signs of Pneumonia?
4 Signs of Emphysema?
5 Sign of Pleurisia?
6 Signs of Pneumothorax?
7 Any Cough?
8 Difficulty Breadthing ?
9 Sign of Hematemesis?
10 Sign of Expectorates?
11 Oxygen user?
12 Other findings?
If any finding or sign of abnormalities related to Pulmonary examination ?
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PART:D GASTRO-INTESTINAL SYSTEM EXAMINATION

IF ANY ABNORMAL FINDINGS PLEASE SPECIFY IN ALL THE FOLOWING AREAS
Normal Abnormal
1 Any signs of recurrent Dental, oral swelling issues?
2 Any signs of recurrent Heartburn, or Hiatus Hernia?
3 Any signs of recurrent Abdominal pain, Nausea or vometing ?
4 Any history of Gastric, Duodenal or Peptic ulcer?
5 Any signs of Gastro-intestinal / Rectal bleedings or irritable Bowel Syndromes?
6 Any signs of reactive abdominal palpation/percussion of signs of abdominal Hernia?
7 Any history of Crohn's Disease or Ulcerative colitis ?
8 Results or rectal examination and signs of Hemoroids ?
9 Any signs of liver or Gallbladder disfuction?
10 Any signs of pancreas disfuction?
11 Any signs of splen size increse
12 Other gastrointestinal findings
If any finding or sign of abnormalities related to Metabolic, endocrine or immune system examination?
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PART:E METABOLIC -ENDOCRINE & IMMUNE SYSTEM EVALUATION

General results of Metabolic - Endocrine & Immune System Examination?
Normal Abnormal
1 Any weight or appetite changes
2 Any signs of Diabetes
3 Any signs of Thyroid Disfunction
4 Any sign of Adrenal Gland Disease
5 Any sign of other hormonal disfunctions /Hypotalamus and other gland
6 Immune illness related problems
7 Lymphatic system examination
8 Any sign of malignities
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 DERMATOLOGY AND SKIN EXAMINATION

General results of Dermatology and Skin Examination?
IF ANY ABNORMAL FINDINGS PLEASE SPECIFY IN ALL THE FOLOWING AREAS
Yes No
1 1. Any signs of allergies or Urticaria
2 Any signs of Psoriasis?
3 Any signs of Eczema?
4 Any signs of Allergic dermatitis?
5 Any signs of Skin infections?
6 Any signs of Vetiligo or Allopecia ?
7 Sign of nevus changes or skin cancer?
8 Any signs of other Skin problems ?
If any finding or sign of abnormalities related to dermatology and skin examination?
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PART:G MUSCULO-SKELETAL SYSTEM EXAMINATION

General Results of Musculo-Skeletal System Examination?
IF ANY ABNORMAL FINDINGS PLEASE SPECIFY IN ALL THE FOLLOWING AREAS
Normal Adnormal
1 Any sign of pain, arthritis, Rheumatisme, gout, dislocations, myopathies, atrophies or swellings?
2 Head
3 Neck
4 Back
5 Shoulder
6 Elbows
7 Handleds
8 Hips
9 Knees
10 Ankles
11. Any signs or history of Osteopoorosis or recurrent fractures ?
12 Any other findings related to musculo-skeletal system?
If any finding or sign of abnormalities related to the Musculo-skeletal examination ?
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PART:H NERVOUS SYSTEM & CRANIAL NERVES EXAMINATION

General Results of Nervous System & Cranial Nerves Examination?
IF ANY ABNORMAL FINDINGS PLEASE SPECIFY IN ALL THE FOLLOWING AREAS
Normal Adnormal
1 Any signs of headaches, migraines, vertigo, dizziness or problems with balance?
2 Any sign of deficiencies of the nervous system like, neuritis, paralysis or multiple sclerosis?
3 Any signs of Epilepsy, fits, blackouts, fainting turns or unexplained loss of consciousness?
4 Any signs of limb motor or sensory symptoms, loss of coordination or pathologic reflexes?
5 Any visual defect or signs of reduced visual field, blindness, color blindness or night blindness?
6 Any sign of blurred vision or conditions such as glaucoma, Cataract or detached retina issues?
7 Any signs of previous eye(s) Injury or surgery to including laser eye surgery or vision correction?
8 Any signs of Ear infection, discharge, tinnitus, a hearing defect including deafness?
9 Any sign of defect in your testing and smelling abilities?
10 Any signs of Speech or reading disfuctions or disabilities ?
11. Any signs of Writing skills and memory deficiencies?
12 Any sign of other problems related to the nervous system or sences abilities and performance?
If any finding or sign of abnormalities related to the Neuro-Cranial examination?
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PART:I PSYCHOLOGY AND MENTAL HEALTH EVALUATION

General Results of Psychology and Mental Health Evaluation?
IF ANY ABNORMAL FINDINGS PLEASE SPECIFY IN ALL THE FOLOWING AREAS
Yes No
1 Any signs or history of Anxiety/Depression, phobias, breakdowns or stress related Problems?
2 Any signs of Mental Illness, cognitive disorders, such as: Cenility, Alzheimer or Dementia?
3 Any signs or history of disorders affecting learning, memory, perception and problem solving?
4 Any signs or history of eating disorder e.g., anorexia nervosa or bulimia?
5 Any signs or history of Substance misuse? Medecines, drugs, Alcohol or others?
6 Any signs or history of sleeping disorder?
If any finding or sign of abnormalities related to the Mental Evaluation?
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PART:J GENITO-URINARY SYSTEM EXAMINATION

General Results of Renal and Urinary System Examination?
IF ANY ABNORMAL FINDINGS PLEASE SPECIFY IN ALL THE FOLOWING AREAS
Yes No
1 Any signs or history of Frequency in urination?
2 Any signs or history of Pain with micturition?
3 Any signs or history of Urethral discharge?
4 Any signs or history of Blood in urin or changes of urine color?
5 Any signs or history of Kidney stones?
6 Any signs or history of Urgency in Urination?
7 Any signs or history of Incontinence?
8 Any signs or history of Recurrent kidney or urinary tract infection?
9 Any signs or history of Cystitis /urinbladder infrctions?
10 Any signs or history of Urethritis?
If any finding or abnormalities related to the Renal and urinary system examination?
NOTE: THAT IF THE USER GENDER IS SELECTED, THE USER WILL AUTOMATICALLY GO TO THE QUESTION ACCORDING TO THEIR GENDER.
Genitalia MEN
General Results of Male genitalia Examination ?
IF ANY ABNORMAL FINDINGS PLEASE SPECIFY IN ALL THE FOLOWING AREAS
Yes No
11 Any signs of history of issues with the Prostate?
12 Any signs or history of testicular issues?
13 Any actual or previous Epididymes issues?
14 Any actual or previous sexually transmitted infection?
15 Any sexuality issues , problems with errection etc.?
If any finding or abnormalities related to the Renal and urinary system examination?
Genitalia WOMEN
General Results of Female Genitalia Examination ?
IF ANY ABNORMAL FINDINGS PLEASE SPECIFY IN ALL THE FOLOWING AREAS
Yes No
16 Any actual or previous problem with the menstruation
17 Is the examinee in Menopause phase
18 Any signs or history of breast lumps or disorder
19 Any signs or history of breast cancer?
20 Any sexuality issues , problems with errection etc.?
21 Any history of abnormal pap smear test?
22 Any aborts or complications during any pregnancies?
23 Any signs of sexully transmited infections
24 Any signs or history of disfuction of sexuality related issues
If any finding or abnormalities related to the Renal and urinary system examination? Overall Findings Diagnosis or prescriptions: If any additional medical findings not listed in this questionnaire or if you have any other medical recommendation after this systemic examination?,
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