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- CMQ - Summary - Amended Copy

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Country of origin: CANADA
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COMPREHENSIVE MEDICAL QUESTIONAIRE
1
SURNAME:
FIRST NAME:
BC HEALTH CARE NUMBER: (Patient’s without a valid
BC Medical number will not be accepted)
DATE OF BIRTH:
HOME ADDRESS:
PROVINCE: POSTAL CODE:
PRIMARY PHONE #
ALTERNATE PHONE #
E-MAIL ADDRESS
PREVIOUS FAMILY PHYSICIAN:
CURRENT HEALTH CONCERNS
(Please list any significant medical problems that you are currently concerned about)
Problem
Date of Onset
Comments
(1)
(2)
(3)
(4)
(5)
(6)
(7)
COMPREHENSIVE MEDICAL QUESTIONAIRE
2
MEDICATIONS AND ALLERGIES –
(PLEASE NOTE – THE DOCTORS AT THIS OFFICE DO NOT
PRESCRIBE NARCOTIC MEDICATIONS TO NEW PATIENTS)
(Please list your current medications and allergies to medications)
Nature of Allergic Response When Taken
OTHER ALLERGIES AND IMMUNIZATIONS Comments
Do you have any allergy problems?
Yes
No
Do you have hay fever symptoms?
Yes
No
Do you have food allergies?
Yes
No
Have you had a tetanus shot?
Yes
No
Date:
Do you get an annual flu vaccine?
Yes
No
Have you had a pneumonia vaccine?
Yes
No
Have you had a polio immunization series?
Yes
No
Have you had recent immunizations?
Yes
No
List:
Have you had a tuberculosis skin test?
(Mantoux Test)
Yes
No
Date:
Result: Positive Negative
COMPREHENSIVE MEDICAL QUESTIONAIRE
3
SIGNIFICANT PAST HISTORY
(Please list any significant illnesses, including hospitalizations, you have had in the past)
Illness
Year
Comments
Hospitalization
Year
Hospital and City
Surgery
Year
Hospital and City
OTHER SIGNIFICANT TREATMENTS
(Please list any other significant treatments you have received such as radiation, chemotherapy, or other)
Treatment
Year
Comment
COMPREHENSIVE MEDICAL QUESTIONAIRE
4
SIGNIFICANT FAMILY HISTORY
(Please list any family history you have regarding the following conditions)
Health Problem
Yes
No
Comments
Diabetes Mellitus
High Blood Pressure
(Especially under age 50)
Stroke
(Especially under age 50)
Heart Attack
(Especially under age 50)
Heart Surgery or Bypass
(Especially under age 50)
Breast Cancer
Colon Cancer
Lung Cancer
Prostate Cancer
Other Cancers
Arthritis or Joint Replacement
Back Pain
Sudden Death
Thyroid Disease
Osteoporosis
Obesity
Other Diseases
COMPREHENSIVE MEDICAL QUESTIONAIRE
5
SIGNIFICANT PERSONAL HABITS
(Please complete the following information on your personal habits and health risks)
TOBACCO
Yes
No
Comment
Did you live with people who smoke?
Did your Parents smoke?
Father __
Mother__
Have you ever used tobacco?
Do you currently use tobacco?
Cigarettes
Amount
Cigars
Amount
Pipe
Amount
Smokeless Tobacco
Amount
ALCOHOL
Yes
No
Comment
Do you drink alcoholic beverages?
Beer?
Amount
Per week?
Wine?
Amount
Per week?
Hard Liquor / Spirits?
Amount
Per week?
Did you used to drink alcohol?
Have you ever considered alcohol to be
a personal problem?
Have you ever felt you should cut
down on your drinking?
Have people ever annoyed you by
criticizing your drinking?
Have you ever used alcohol to get over
a hangover?
Has drinking ever affected your job?
Have you ever driven your vehicle
when you know you are intoxicated?
Have you ever been charged with
driving while intoxicated?
OTHER COMMENTS
COMPREHENSIVE MEDICAL QUESTIONAIRE
6
DIETARY HABITS
(Please enter the following information regarding your diet)
Question
Yes
No
Comment
Are you comfortable with your weight?
Why?
Have you been losing weight?
Amount?
Would you like to lose weight?
Amount?
Do you have an ideal weight for you?
Amount?
Have you tried to diet in the past?
Which diets?
Do you have any dietary restrictions?
What?
Do you eat 3 meals a day?
If No, Then
How Many?
Yes
No
Do you drink coffee?
If Yes
How Much?
Do you drink caffeinated teas?
If Yes
How Much?
Do you drink caffeinated colas or soda?
If Yes
How Much?
Do you drink diet colas or soda?
If Yes
How Much?
Do you drink milk?
If Yes How Much?
What type? Skim 1% 2% Whole
Do you drink water?
How much?
What type? Tap Distilled Bottle
Do you take dietary supplements,
vitamins or minerals?
Please list all that you take.
COMPREHENSIVE MEDICAL QUESTIONAIRE
7
ACTIVITY LEVEL
(Please enter the following information regarding your level of physical activity)
Circle below the level of physical activity that you think you have in comparison to others your same
age and sex
Sedentary
Mild Activity
Average Activity
Quite Active
Very Active
Please answer the following questions
Yes
No
Comment
Are you on an exercise program?
Are you consistent with your program?
Do you enjoy exercise?
Do you have any musculoskeletal
concerns, restrictions or disabilities?
If you exercise, please provide the following information regarding safety when you exercise.
Yes
No
Comment
Do you warm up before exercise?
Do you cool down after exercise?
Do you know how to take your pulse?
Do you monitor your heart rate?
Do you wear protective equipment
when necessary?
SLEEPING HABITS
(Please answer the following questions about your sleep)
Never
Sometimes
Always
Do you sleep enough hours each day?
Are you rested?
Do you have to use an alarm to wake up?
Do you have to catch up on your sleep?
Do you ever wish you could nap after lunch?
Back
Side
Stomach
Please indicate your usual sleeping posture (s)
Yes
No
Do you sleep with a pillow
Do you use a special type of pillow?
Type?
COMPREHENSIVE MEDICAL QUESTIONAIRE
8
WOMENS HEALTH CONCERNS
(Please complete the following information)
Date of Last
Menstrual Period?
Date of Last
Pelvic Examination?
Date of Last
PAP Test?
Date of Last
Breast Examination?
Date of Last
Mammography?
Yes
No
Comments
Have you had a hysterectomy?
When?
Have you had any other gynecological
(female) surgery?
What?
Have you had an abnormal pelvic
exam?
Have you had an abnormal PAP test?
Are your periods abnormal?
Do you have urine loss when you
cough sneeze or laugh?
Are you currently using birth control?
Type?
Have you been pregnant?
Number
Of times?
Yes
No
Comments
Do you experience any premenstrual
tension or depression?
Do you do breast self-examination each
month?
Which Day
Of The Month?
Are you aware of any breast lumps?
Do you have any nipple discharge or
abnormal bleeding?
Have you ever had a breast biopsy?
Have you had any other breast surgery?
What?
Please list any other current concerns you may have regarding your female health.
COMPREHENSIVE MEDICAL QUESTIONAIRE
9
STRESS AND EMOTIONAL FACTORS
(Please answer the following questions as carefully as you can)
Yes
No
Comments
Do you consider your home life
stressful?
Do you consider your work life
stressful?
Are you married?
How Many Years?
Do you have children?
How Many?
Ages?
Do you consider yourself a tense or
anxious person?
Do you feel you manage stress well?
Are you taking any medications for
emotional or mental health concerns?
(Please list the medication and what
you take the medication for.)
Medication:________________________
Taken For:________________________
Medication:________________________
Taken For:________________________
Medication:________________________
Taken For:
Have you ever been in counseling with
a counselor, psychologist or
psychiatrist?
Why?
Are you currently seeing a counselor,
psychologist or psychiatrist?
Why?
Who?
Please circle the area of your greatest current concern or worry.
Marriage
Family
Work
Finances
Health
Other
Briefly describe your current concern or worry
Please list any significant or traumatic life events. Significant/traumatic life events may include family
of origin or immediate family concerns such as drug/alcoholism, divorce/separation/death, or abuse
(physical, emotional, sexual). It may also include significant conditions such bouts of mental illness,
physical disability or genetic disorders.
1.
2.
3.
Identify your position in your family of origin (e.g., are you a first born or second born, or only child?).
Only Child
First Born
Second Born
Third Born
Fourth Born
(_____) Born
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Completed 7 March 2021

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