MSQ - Poseidonia Healthcare

MSQ

MEDICAL SCREENING
QUESTIONNAIRE

    Before You Begin

    • It’s important you provide us with your medical history. Please complete this on-line medical history form, once submitted our Medical Team will be able to fully review your case and provide you with a personalised Treatment Plan and treatment costs.

    • You must take good care to answer all the questions honestly and to the best of your knowledge. If you don’t, your treatment may be affected and you may not receive a refund.

    • All answers contained in this questionnaire are strictly confidential and will become part of your medical record.

    When you submit this Medical Screening Questionnaire, a copy of the form will be emailed to you for your file.

    Your Personal Details
























    Date Of Birth





    Your Health Concerns

    MEDICAL CONDITIONS: (Please complete as extensively as you think necessary.)

    MEDICAL HISTORY: (Please complete as extensively as you think necessary.)


    General Medical Conditions

    Please tick Yes or No to every question

    Heart or cardiovascular disorders

    e.g. Coronary Artery Disease, Chest Pains, Circulation Problems, Varicose Veins, High Blood Pressure, Venous Ulcers, Chronic Heart Failure, Acute Cardinal infarction

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    Glandular disorders

    e.g. Diabetes, Hyperthyroidism, Hormonal Problems, Thyroid Disease

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    Breathing or respiratory disorders

    e.g. Asthma, Bronchitis, Chronic Obstructive Pulmonary Disease, Shortness of Breath, Upper Respiratory Tract Infection, Chest Infections, Colds, flu, Sinuses Problem

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    Ears, nose, throat, or eye problems

    e.g. Hayfever, Tonsillitis, Sinusitis, Cataracts, Eye Infections, Deafness, Ear Infections, Optic Neuritis, Eustachian Tube Dysfunction

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    Stomach, intestines, liver or gallbladder

    e.g. Ulcer, Colitis, Repeated Indigestion, Irritable Bowel, Change in Bowel Habits, Hepatitis, Piles, Rectal Bleeding, Acute Pancreatitis

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    Cancer, tumours, growths, cysts, or moles that itch or bleed
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    Skin problems

    e.g. Eczema, Rashes, Psoriasis, Acne

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    Brain or nervous system disorders

    e.g. Stroke, Migraines, Repeated Headaches, MS, Epilepsy, Nerve Pain, Fits

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    Muscle or skeletal problems

    e.g. Arthritis, Cartilage and Ligament Problems, Back and Neck Problems, Sprains, Joint Replacements, Gout, Sciatica, Rheumatic Disease

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    Urinary problems

    e.g. Bladder, Kidney or Prostate Problems, Urinary Infections, Incontinence

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    Blood disorders

    e.g. Anaemia, Hepatitis, HIV, Abnormal Blood Tests, Blood Clotting Problems, Thrombocytopenia, Bleeding Organs, Sickle Cell Disease, Haemorrhage/Haematological Disease

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    Reproductive system problems

    e.g. Pregnancy and/or Childbirth Problems, Heavy or Irregular Periods, Fibroids, Endometriosis, Infertility, Abnormal Smears, Menopause

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    Pregnant or Breast Feeding
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    Surgery

    e.g. Ear-Nose-Throat Surgery, Chest Surgery, Vascular Surgery

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    Dental problems

    e.g. Wisdom Teeth, Abscess, Gingivitis

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    Psychological disorders

    e.g. Depression, Schizophrenia, Anorexia, Bulimia, Compulsive Disorders, Stress, Anxiety

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    Undiagnosed symptoms

    e.g. Chest Pain, Fatigue, Weight Loss, Dizziness, Joint Pain, Change in Bowel Habit, Shortness of Breath, Abdominal, Pain, Rectal Bleeding

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    Balance disorder
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    G6 PD deficiency
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    Ozone Allergy/Ozone Intolerance
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    Anti-Thrombotic Medicine or Aspirin
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    High blood Pressure/ Hypertension
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    High cholesterol or lipids
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    Prosthesis (Limb-Teeth)
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    Pyrexia-Fever or unknown fever
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    Alcohol Issues
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    Are you taking the following medication

    Medication: Bleomycin, Cisplatin, Disulfiram, Doxorubicin, Sulfamylon

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    Are you taking any medicines not listed above
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    Is there any other information relating to your health that has not yet been prompted by the questions listed above. If so, please add details below.
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    Other Frequent Symptoms Or Conditions You May Experience
    List Other Symptoms Or Conditions Not Listed Above
    Over-The-Counter Drugs - Please Check All That Apply To You.
    Do you have any of the following allergies
    Family Medical History
    Other Therapy

    e.g. Have you received Hyperbaric Oxygen Therapy, ozone or stem cells before?

    Please indicate your normal blood pressure levels (if not sure, please ask your doctor or local Pharmacy)




    When providing a digital signing above, I agree that the signature will be the electronic representation of my signature and for all purposes when I use them on documents - just the same as a pen-and-paper signature.