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The following questionnaire will help us assess your health status, while it is necessary for any advice you will receive on your lifestyle.

Thank you

All answers are strictly confidential

PERSONAL DETAILS

FAMILY HISTORY

DIET

1. How many times weekly do you consume:
Red Meat Chicken Fish Pulses
Green vegetables Fruit Salad Dessert
2. Do you add salt to your meals?
3. How many cups of coffee do take daily?
4. Is your weight stable?

LIFESTYLE

1. Exercise:
How many times weekly do you exercise for more than 30 minutes?
What type of exercise do you do?
Do you smoke Cigarettes?
Do you smoke Cigars?
Do you smoke Pipe?
If yes, how many a day?
How long have you been smoking?
If you don't smoke any more, when did you quit?
How much did you smoke every day?
I have never smoked
3. Alcoholic drinks (How many times a week?)

PAST MEDICAL HISTORY

1. Have you ever had any of the following? Tick the appropriate box
Heart conditions   Diabetes
  Heart attack High blood pressure
  Angina High cholesterol
  Balloon/stent Asthma
  Open heart surgery Other
  Valve disease
  Enlarged heart
2. Have you ever had any operations? What, when?
3. Have you ever been admitted to hospital other than for an operation? Why, when?
4. Other symptoms
Chest pain Weakness
Shortness of breath Palpitations
Dizzy episodes Other
Fatique
5. Do you take any regular medication? Write down their names:
6. Are you allergic to anything?
7. Specifically for women
Are your periods normal?
 
Have you been through the menopause?
Personal doctor's name:  
I would like to have the results sent to my doctor:
I hereby give my consent for my personal details to be used by Cardiodiagnosis Medical Centre for administrative/medical reasons.