The following questionnaire is an important part of your medical.
Before arriving for your health assessment we would be grateful if you would complete the following questionnaire as far as possible and bring it with you to your appointment to discuss with the doctor. Alternatively you may like to email the completed questionnaire back to us ready for your appointment.
Don’t worry if there are questions that you can’t answer as these can be discussed during the assessment.
Note to previous patients: If you have had a medical in the last 2 years with Dr Kelly and Associates you need only complete the new areas of information or information that was not given at your last medical.
Next of Kin
Address of Next of Kin
Job Title or Role
Please give the current age and state of health of the following relatives, or if deceased, their age and the cause of death
Is there a family history of any of the following (Grandparents, parents, brothers, sisters)? If appropriate please provide details.
How much alcohol do you drink on average per week in units?
Please look at the symptom check list below
Please list below any other symptoms or problems you would like to discuss with your doctor?
A certain amount of stress is inevitable in all our lives.
However, excess stress can have an adverse effect on our health and functional level. Some people do not realise when their health is being adversely affected.
They may be tired and irritable, shouting at their partner or children, or sleeping poorly with early morning wakening. Their appetite may be poor or they may ‘comfort eat’.
They may become withdrawn and start to drink alcohol excessively or take ‘recreational’ drugs. As part of yourhealth assessment we would like to try to get some idea of your stress levels and how you are coping with them.
The questionnaire is designed to highlight areas for possible discussion with the Doctor. It is treated in the strictest confidence.
Please complete the following questions by entering a number on a scale between 1-10, with 1 being the least stressed.
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE
We will contact you by email to let you know when your Report is ready and provide instructions on how to access your Report.
Please confirm the email address you would prefer we use to contact you regarding your report.