Daedalos Institute, Ltd.                                                       
A Health Informatics' Company

Please describe, in English,  your questions relating to your health problems wanted us to address. Then fill the General Medical History Questionnaire below and summit it to us by clicking the submit button:

GENERAL MEDICAL HISTORY FORM
 

1. Your Birthrate:

2. Weight Kg. or  Weight Lb. 

3. Height in cm.: or Height in inch.

4. Chief complaint:

5. Location:

6.Do you have any symptoms?YesNo

7. If "Yes", please, describe the symptoms?

8. How long have you had these symptoms?

9. How long do they last?

10. What causes these symptoms or makes it better or worse?

11. What time of the day do these symptoms occur?

12. How severe is it?

13. Any other associated signs or symptoms?

14. How is your general health?

15. Do you have fevers? YesNo

16. Have you had recent involuntary weight loss? YesNo

17. If "Yes",  how much  and since when ?

18. Do you have any problems with your ears, nose, throat or mouth? YesNo

19. If "Yes", please, describe them

20. Do you have any problems with your Heart or Blood pressure ?  YesNo 

21. If "Yes", please, describe them

22. Do you have any breathing problems ? YesNo

23. If "Yes", please, describe them

24. Do you have any eating or bowel  problems? YesNo

25.If "Yes", please, describe them

26. Do you have any kidney or bladder problems? YesNo

27. If yes, please describe them

28. Do you have any muscle problems? YesNo

29.If yes, please describe them

30. Do you have any skin problems? YesNo

31. If yes, please describe them

32. Do you have any breast problems? YesNo

33. If "Yes", please, complete the Breast Evaluation Form by  

34. Do you have any neurological or psychological problems? YesNo

35. If "Yes", please, describe them

36. Do you have any thyroid problems? YesNo

37. If "Yes", please, describe them

38. Do you have any  problems with diabetes (or high blood sugar)? YesNo  

39. If "Yes", please, describe them

40. Do you have any blood  problems? YesNo

41. If "Yes", please, describe them

42. Do you have any allergies? YesNo

43. If "Yes", please, describe them.

44. Have you had any operations? YesNo

45. If "Yes", please, describe them.

46. What medications do you currently take including non-prescription drugs?

47. Are there any disease that run in your family? YesNo

48.If "Yes", which one ? CancerNoneDiabetesHeart DiseaseOthers

49. If you worry about your risk for getting cancer, please, fill out the Cancer Risk Evaluation form by

49. If others, please, describe it

50. Do you smoke?  YesNo

51. If "Yes", how many packs per day?

52. Do you drink alcohol?  YesNo

53.If "Yes", how many drinks per day?

54. What is the diagnoses given to you by your doctors concerning your current complains?

55. What is the treatment prescribed by your doctor for you current condition?

56. Do we have your permission to share your medical information?  YesNo

57. If yes , with whom do we have your permission to share your medical information?

58. In order to communicate with you, we need your Personal Identification Number or PIN:  

If you have not a PIN ,please,  to obtain a PIN:

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