Dr Kelly Health Screening Questionnaire

Dr Kelly Health Screening Questionnaire

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.


About You
Your GP
GP Name
GP Address
Would like a copy of your results to be sent to your GP?
Cost Code
Leave blank if not known
Next of Kin
Name of Next of Kin
Relationship with Next of Kin
Address of Next of Kin
Telephone Number of Next of Kin
Please indicate whether you would like a chaperone to be present during the examination
Your Occupation
Company Name
Company Address
Job Title or Role
What percentage of the working day do you estimate you spend at the computer?
Do you travel internationally for work? If so, how frequently?
What percentage of international work travel involves flights longer than 4 hours (actual flight time)?
Family History

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 many times per week do you exercise?
How much brisk walking do you do per day?
Smoking
If yes, approximate number per day?
How much alcohol do you drink on average per week in units?
(1 unit is equivalent to 1 small glass of wine, 1⁄2 a pint of beer or lager or a short of spirit)
Do you have a special diet?
If yes, please give details
Do you estimate that you eat 5 portions per day of fruit and vegetables?
Have you ever had raised cholesterol?
Do you take any vitamin/mineral supplements?
Do you have diabetes, thyroid problem, arthritis, asthma, depression or any diagnosed medical illness?
If Yes, please give details.
Have you had any medical treatment or investigations in the past six months?
Are you awaiting a specialist appointment?
Are you on any medication, including the contraceptive pill or non-prescribed medication, at the moment?
If Yes, please give details.
Do you have any allergies to medication or other substances?
If Yes, please give details.
How many sickness days do you estimate that you have taken from work in the past two years?
Have you ever had or do you think you may have any work-related illness or condition?
If Yes, please give details.
Have you ever been in hospital?
If yes, please give details of approximately when and what for
Please look at the symptom check list below
Please give the approximate date of your last cervical smear test?

Women only

Have you had any abnormal cervical smear tests?

Women only

If Yes, please give details.
Have you had any abnormal pregnancies or complications of pregnancy?

Women only

If yes, please give details
Please list below any other symptoms or problems you would like to discuss with your doctor?
Optional
Stress

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.


Your personal information will be held securely and kept private. We will exclusively use the information you submit to provide a quotation. You will not be added to our mailing list without your permission. View privacy policy >

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.