GNG HEALTH SCREENING FORM

TEL: 0540200707 / 0503517073 , PANTANG RAOD

HEALTH SCREENING QUESTIONNAIRE

ID:

1. PERSONAL DETAILS AND BASIC EXAMINATIONS

Name: Age: Weight: kg Height: m

Blood pressure Pulse : bpm
Gender: Address:
(mmHg)
Occupation : Contact: Temp: C Spo2 : %

2. MEDICAL SCREENING CONSULT

Tick ( ) to Yes replies, leave space empty if No

Any Complaints

Symptoms Enquiries
General Symptoms Fever ( ), Loss Of App ( ), Difficulty Breathing ( ) , Pedal Swelling ( )
Weight Loss ( ) , Night Sweats ( ) Easy Fatigue ( ), Headache ( )
Comments:
Respiratory Cough ( ) , Runny Nose ( ) , Chest Pains ( )
Symptoms comments:
Gastrointestinal Abd Pains ( ) , Heart Burns ( ) Nausea ( ) , Vomiting ( ) ,
Symptoms Watery Stool ( ) , Constipation ( ), Blood In Stool ( ),
comments:
Cardiovascular Palpitation ( ) , Orthopnoea ( )
symptoms comments :

Genitourinary Painful urination ( ) , Urinary frequency ( ) , Blood in urine ( )

symptoms
For women : vaginal discharge ( ) , menstrual irregularity ( ) ,
Pain during sex ( ) , genital rashes ( ) , itchy vaginal ( )
For men : penile discharge ( ) , erectile dysfunction ( ) , genital rashes ( )
Comments:
Neurological blurred vision ( ) , changes in colour vision ( ), sudden loss of vision ( )
symptoms muscle weakness ( ) , numbness( ), confusion ( ), loss of memory ( )
comments:
Dermatological Rashes ( ) Skin lesions( ) Skin colour changes( )
symptoms Body itchiness ( )
Comments :
ADDRESS: P.O BOX AF 1948
LOC: BESIDE RAGLO INTERNATIONAL SCHOOL ON PANTANG ROAD
TEL: 0540200707/ 0503517073
 GNG HEALTH SCREENING FORM
TEL: 0540200707 / 0503517073 , PANTANG RAOD

3. Past Illness

Any Current illness Or Yes ( ) No ( )

Chronic illness If Yes , list here :

4. List of medications you take on a regular basis.


5. Allergies :
6. Lifestyle and habits
 Do you exercise on regular basis? : Yes ( ) No ( )
 Do you smoke cigarettes on regular basis? Yes ( ) No ( )
 Do you take alcohol on regular basis? Yes ( ) No ( )
7. Basic laboratory test

Test Results Test results

Blood sugar level mmol/L Total cholesterol mmol/L
Total uric acid mg/dL HB level g/dL
Malaria test Typhoid test IGG ( ) IGM ( )
Hepatitis B Hepatitis C
Syphilis test HIV test

8. Doctor’s comments ( Basic physical examination, possible diagnosis and prescription

given, possible referral )

ADDRESS: P.O BOX AF 1948

LOC: BESIDE RAGLO INTERNATIONAL SCHOOL ON PANTANG ROAD
TEL: 0540200707/ 0503517073