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Health Questionnaire
Health Questionnaire
Questions
1.since how many years diabetes is there? What kind of symptoms do you experience?
3.any other major medical or surgical illness in the past? Taking any medicine for the same?
DIABETES TYPE 2
Questions
1.Since how many years do you have diabetes? What kind of symptoms do you experience?
2.Are you taking medicines or insulin for it?please send the names and doses.
Questions
1.Since how many years are you suffering from high blood pressure?
2.What medicines are you taking for it? Please mention with doses.
HYPOTENSION
Questions
1.Since how many years are you having low blood pressure problems?
3.Do you take medicines for it? Please mention with doses.
Questions
6.Any major medical or surgical illness in the past? Any medicines for it?
MYALGIA/FIBROMYALGIA
Questions
3.What medicines are you taking for it? Please mention with doses.
5.Any major medical or surgical illness in the past? Any medicines for it?
LOWER BACKACHE
Questions
1.Since when do you have the back pain? Please describe the nature of the pain and any other
symptom along with it?
2 . Are you taking any medicines for it? Please mention with doses.
Questions
4. Do you have high blood pressure, diabetes or any other major medical or surgical illness in past?
EYE SIGHT
Questions
3.Are you using any medicines for it? Please share details.
EMOTIONAL BLOCKAGES
Questions
3.Do you take any medicines for it? Please share with doses.
4.Do you have any major medical or surgical illness in the past?
LUPUS
Questions
1.Since how many years do you have lupus?
4.Do you have any skin problems, joint problems or swelling in any part of the body?
CELLULITIS
Questions
5.Do you diabetes, high blood pressure or any other major medical or surgical illness in past?
SHINGLES
2.Where do you have the blisters or pain? Can you share a picture?
UTERINE FIBROIDS
Questions
3.Do you take any medicines for it? Please share details.
5.Do you have any other major medical or surgical illness in the past?
ENDOMETRIOSIS
Questions
2.What are the symptoms you have? Pain, irregular blood flow or anything else.
3.Do you take any medicines for it? Please share details.
5.Do you have any other major medical or surgical illness in the past?
Questions
OSTEOPOROSIS/OSTEOARTHRITIS/BURSITIS/FROZEN SHOULDER
Questions
5.Have you undergone any tests for it? Please share details.
HAIR LOSS/ALOPECIA
Questions
7.Do you have any digestive disturbances? Are your bowels regular?
TESTOSTERONE
Questions
ERECTILE DYSFUNCTION
Questions
PARKINSONS DISEASE
Questions
4.Do you suffer from any mental stress, mood swings or memory loss?
8.Any other major medical or surgical illness? Please share the medicine details?
ALZHEIMERS DISEASE/DEMENTIA
Questions
5.Do you suffer from any mental stress, mood swings or memory loss?
8.Any other major medical or surgical illness? Please share the medicine details?
9.List of medications currently taking.
NICOTINE ADDICTION/SMOKING
Questions
7.Do you get sound sleep? Do you feel refreshed after sleeping?
Questions
1. Since how many years are using the drug ? How many times a week?
7.Do you get sound sleep? Do you feel refreshed after sleeping?
CANCER
Questions
2.Any surgery done for it? Undergone any therapy for it?
1. Since how many years kidney disease is there? What kind of symptoms do you experience?
3. Any other major medical or surgical illness in the past? Taking any medicine for the same?
3.Do you have any other major medical or surgical illness? Please share the list of medicine if any.