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Details of Person Completing the Form
Name of Person Completing the Form
*
First
Last
Phone-number of Person Completing the Form
Email of Person Completing the Form
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Personal Details of Patient
Name
*
First
Last
Date of birth
*
Date of birth
Email
*
Phone
*
Gender
*
Male
Female
Home country
*
Physical address of residence
*
Current Citizenship
Marital Status
Home language
*
Other languages
Current employment
Share some details of your current employment
How many dependants do you have?
Do you have health insurance?
Yes
No
Details of your PARTNER or SPOUSE
Partner/Spouse Name
First
Last
Partner/Spouse Email
Partner/Spouse Phone
Partner/Spouse Gender
Male
Female
Details of a FRIEND or RELATIVE
Friend/Relative Name
First
Last
Friend/Relative Email
Friend/Relative Phone
Relationship
Background
How did you hear about Dr Erasmus?
*
What is the main health problem that you are seeking help for from Dr Erasmus?
*
Give as much detail as possible.
Medical & Surgical Conditions
Please list all medical and surgical CONDITIONS or symptoms which are a problem to you now. SINCE WHEN you have had it, WHEN it occurs, and what makes it BETTER or WORSE. If possible, you can tell us in which year each condition was diagnosed, and how the diagnosis was made (e.g. by a doctor, with a scan, etc.)."
Health condition
Information
Please complete all of the below information, or indicate if you do not have this information available. If you do not measure these parameters at home, please write the last measurement that was tested by a doctor or nurse or pharmacy (or measured by a home-machine).
Height
cm
Weight
kg
BMI current
BMI last year
Upper arm circumference
mm
Blood pressure
Blood sugar
Pulse at rest
Fitness level
Unfit
Getting Started
Improving
Fit
Athlete
How far can you walk before becoming out of breath?
km
How far can you jog/run before becoming out of breath?
meters
How comfortable are you with mountain hikes?
Very Uncomfortable
Somewhat Uncomfortable
Neutral
Comfortable
Very Comfortable
Do you presently have any wounds?
Do you have any knee or foot injuries?
Do you need assistance with
Bathing
Toilet
Walking
Eating
Remedies
Please list all natural remedies and supplements/herbs you use, and indicate how frequently you use them:
Natural remedies and supplements
Treatment History
Medications
Write down all the MEDICATIONS you are taking NOW and include dosage and frequency. (Include birth control pills, pain medications, diet hormones, vitamins, minerals, and supplements.)
Stopped medications
Please list all medications you have used during the past year but not using currently (e.g. if you used blood pressure medication and stopped it, you can tell us the name of the medication, and when you last used it.
Allergies
Please list all ALLERGIES and reactions to medications.
Reactions
You can also tell us about reactions you get to other things, e.g. cleaning materials, animals, etc.
Childhood illnesses
List major childhood illnesses and procedures:
Illnesses
What serious ILLNESSES have you had – both physical and mental? Please indicate the date (e.g. stroke, heart attack):
Procedures
What SURGICAL OPERATIONS/PROCEDURES or SERIOUS INJURIES have you had? Please indicate the date.
Blood transfusion
Have you ever had a BLOOD TRANSFUSION? (when)
Vaccinations
Please list all vaccinations and other courses of injections you have received during the past 5 years.
Family History
Illnesses of relatives:
List major illnesses of relatives:
Health problem - Frequency
Feel free to share details where applicable
Weight gain
In the past only
Rarely
Frequently
No not at all
Weight gain comments
Weight loss (planned)
In the past only
Rarely
Frequently
No not at all
Weight loss (planned) comments
Weight loss (unintentional)
In the past only
Rarely
Frequently
No not at all
Weight loss (unintentional) comments
Fever or night sweats
In the past only
Rarely
Frequently
No not at all
Fever or night sweats comments
Fatigue
In the past only
Rarely
Frequently
No not at all
Fatigue comments
Itching or skin rash
In the past only
Rarely
Frequently
No not at all
Persistent itching or skin rash comments
Blisters
In the past only
Rarely
Frequently
No not at all
Blisters comments
Warts or moles
In the past only
Rarely
Frequently
No not at all
Warts or moles comments
Skin cancers
In the past only
Rarely
Frequently
No not at all
Skin cancers comments
Eczema
In the past only
Rarely
Frequently
No not at all
Eczema comments
Acne
In the past only
Rarely
Frequently
No not at all
Acne comments
Dry eyes
In the past only
Rarely
Frequently
No not at all
Dry eyes comments
Other eye problems
In the past only
Rarely
Frequently
No not at all
Other eye problems comments
Difficulty hearing
In the past only
Rarely
Frequently
No not at all
Difficulty hearing comments
Ear ache or pains
In the past only
Rarely
Frequently
No not at all
Ear ache or pains comments
Tinnitus
In the past only
Rarely
Frequently
No not at all
Tinnitus comments
Hearing aids
In the past only
Rarely
Frequently
No not at all
Hearing aids comments
Throat infection
In the past only
Rarely
Frequently
No not at all
Throat infection comments
Voice changes
In the past only
Rarely
Frequently
No not at all
Voice changes comments
Throat pain
In the past only
Rarely
Frequently
No not at all
Throat pain comments
Hayfever
In the past only
Rarely
Frequently
No not at all
Hayfever comments
Abnormal breathing
In the past only
Rarely
Frequently
No not at all
Abnormal breathing comments
Asthma or wheezing
In the past only
Rarely
Frequently
No not at all
Asthma or wheezing comments
Triggers for coughing
In the past only
Rarely
Frequently
No not at all
Triggers for coughing comments
Persistent cough
In the past only
Rarely
Frequently
No not at all
Persistent cough comments
Exposure to tuberculosis
In the past only
Rarely
Frequently
No not at all
Exposure to tuberculosis comments
Past TB diagnosis
In the past only
Rarely
Frequently
No not at all
Past TB diagnosis comments
Current TB diagnosis
In the past only
Rarely
Frequently
No not at all
Current TB diagnosis comments
Chest pain
In the past only
Rarely
Frequently
No not at all
Chest pain comments
Shortness of breath with heavy exercise
In the past only
Rarely
Frequently
No not at all
Heavy exercise comments
Shortness of breath with heavy exercise comments
Shortness of breath with mild exercise
In the past only
Rarely
Frequently
No not at all
Mild exercise comments
Shortness of breath with mild exercise comments
Shortness of breath at rest
In the past only
Rarely
Frequently
No not at all
Shortness of breath at rest comments
Faintness or dizziness or nausea on exertion
In the past only
Rarely
Frequently
No not at all
Faintness or dizziness or nausea on exertion comments
Faintness or dizziness or nausea on exertion (i.e. with mild activity) comments
Swelling feet/ancles
In the past only
Rarely
Frequently
No not at all
Swelling feet/ancles comments
Abnormal heart tests?
In the past only
Rarely
Frequently
No not at all
Abnormal heart tests comments
Past heart surgery?
In the past only
Rarely
Frequently
No not at all
Past heart surgery comments
Previous heart attack diagnosed?
In the past only
Rarely
Frequently
No not at all
Previous heart attack diagnosed? Comments
Blood clots (phlebitis)
In the past only
Rarely
Frequently
No not at all
Blood clots (phlebitis) comments
Stomach or bowel problems
In the past only
Rarely
Frequently
No not at all
Stomach or bowel problems comments
Bloating
In the past only
Rarely
Frequently
No not at all
Bloating comments
Abdominal pain
In the past only
Rarely
Frequently
No not at all
Abdominal pain comments
Nausea
In the past only
Rarely
Frequently
No not at all
Nausea comments
Vomiting
In the past only
Rarely
Frequently
No not at all
Vomiting comments
Constipation
In the past only
Rarely
Frequently
No not at all
Constipation comments
Diarrhoea
In the past only
Rarely
Frequently
No not at all
Diarrhoea Comments
Diverticulitis diagnosed
In the past only
Rarely
Frequently
No not at all
Diverticulitis diagnosed Comments
Abnormal colonoscopy
In the past only
Rarely
Frequently
No not at all
Abnormal colonoscopy Comments
Abnormal gastroscopy
In the past only
Rarely
Frequently
No not at all
Abnormal gastroscopy Comments
Burning urine
In the past only
Rarely
Frequently
No not at all
Burning urine comments
Bloody urine
In the past only
Rarely
Frequently
No not at all
Bloody urine comments
Kidney stones
In the past only
Rarely
Frequently
No not at all
Kidney stones comments
UTIs
In the past only
Rarely
Frequently
No not at all
Frequent urinary tract infections
UTIs comments
Kidney failure diagnosed
In the past only
Rarely
Frequently
No not at all
Kidney failure diagnosed comments
Headaches
In the past only
Rarely
Frequently
No not at all
Headaches comments
Dizziness
In the past only
Rarely
Frequently
No not at all
Dizziness comments
Forgetfulness
In the past only
Rarely
Frequently
No not at all
Forgetfulness Comments
Memory loss
In the past only
Rarely
Frequently
No not at all
Memory loss Comments
Mood changes
In the past only
Rarely
Frequently
No not at all
Mood changes Comments
Anxiety or panic
In the past only
Rarely
Frequently
No not at all
Frequent anxiety or panic feelings
Anxiety or panic Comments
Difficulty with self-control
In the past only
Rarely
Frequently
No not at all
Difficulty with self-control comments
Challenges with emotions
In the past only
Rarely
Frequently
No not at all
Challenges with emotions comments
Hallucinations
In the past only
Rarely
Frequently
No not at all
Hallucinations comments
History of substance abuse
Female
Sexual difficulties
(please describe)
Vaginal dryness
In the past only
Rarely
Frequently
No not at all
Vaginal dryness comments
Heavy menstruation
In the past only
Rarely
Frequently
No not at all
heavy bleeding
Heavy menstruation comments
Irregular menstrual cycles
In the past only
Rarely
Frequently
No not at all
Irregular menstrual cycles comments
Known ovarian cysts
In the past only
Rarely
Frequently
No not at all
Known ovarian cysts comments
Cervical cancer or abnormalities
In the past only
Rarely
Frequently
No not at all
Cervical cancer or abnormalities comments
Male
Sexual difficulties
(please explain)
Erectile dysfunction
In the past only
Rarely
Frequently
No not at all
Erectile dysfunction comments
Prostate problems
In the past only
Rarely
Frequently
No not at all
Prostate problems comments
Testicular problems
In the past only
Rarely
Frequently
No not at all
Testicular problems comments
Back pain
In the past only
Rarely
Frequently
No not at all
Back pain comments
Known prostate/testicular cancer
Painful or swollen joints
(please explain)
Joint deformities
(please explain)
Surgery on neck or back
(please explain)
Other bone surgery
(please explain)
Nutrition
Meal/Snack
Please share with us regarding your general/daily routine
Wake-up snack
Yes
No
Sometimes
Wake-up snack time
Breakfast
Yes
No
Sometimes
Breakfast time
Snack
Yes
No
Sometimes
Snack time
Lunch
Yes
No
Sometimes
Lunch time
Afternoon snack
Yes
No
Sometimes
Afternoon snack time
Supper
Yes
No
Sometimes
Supper time
Snack before bed
Yes
No
Sometimes
Snack before bed time
Wake up in the night and eat something
Yes
No
Sometimes
What do you usually have for breakfast?
What do you usually have for lunch?
What do you usually have for supper?
How frequently do you eat/snack between meals?
General/Daily Exercise Routine
Regular exercise program
Are you on a regular exercise program? If so, what type of exercise do you do?
How often do you exercise?
Never
Once a week
Twice a week
Three times a week
More than 4 times a week
Water
Daily water
How many LITRES of water do you drink on an average day?
Weekly
On average, how many of the following do you drink in a week?
Coffee
cups
Caffeinated tea
cups
Hot chocolate
cups
Cola drinks
cups
Fizzy drinks
cups
Soft drinks
cups
Juices
cups
Beer
glass
Wine
glass
Stronger alcohol
glass
Sunlight
Direct sunlight
Yes
No
Do you get exposed to direct sunlight on a weekly basis?
Sunscreen
Yes
No
Do you usually wear sunscreen when you go into the sun?
Sun on a daily/weekly basis
Weather permitting, how many minutes do you spend in the sun on a daily/weekly basis, and what time of day does this usually happen?
Temperance
Define temperance
How would you define the word temperance?
Unhealthy habits
What do you see as unhealthy habits in your lifestyle?
Expel or eliminate
What would you like to expel or eliminate from your lifestyle?
Stop unhealthy habits
Have you ever tried to stop some unhealthy habits, and failed? If so, please share some details with us of what you did to try and break the habit, and what happened.
Air
Where do you live?
Select
City
Suburb
Rural Area
Farm
Coastal Area
Mountain Area
Desert
Forest
Type of breather
Select
Shallow
Deep
Do you see yourself as a shallow or deep breather?
Pets?
Do you have any pets? Please share details about which kind, and where they sleep and spend their time.
Fresh air
Do you make a conscious effort to expose your lungs to fresh air?
Rest
What is your average bed time?
What is your average wake up time?
Daytime naps
Do you take daytime naps? How long?
Working hours
What are your regular working hours?
Stressful event
Have you recently suffered a stressful event, major life change, or severe loss?
Stress
Yes
No
Not sure
Are you under stress?
Source of stress
What would you say is your strongest source of stress?
Stress affect
How does stress affect you?
Stress duration
How long have you been under stress?
Troublesome thoughts
Do you ever have troublesome thoughts of suicide or feelings of severe depression?
Help
Are there people who can help you and have you gone to them for help?
Trust
Do you have any unresolved issues with
God
Spouse
Child
Parent
Relative
Co-Worker
Friend
Enemy
Other
Unresolved issues comments
Do you mostly feel
Optimistic
Loved
Submitted
Amazed
Happy
Remorse
Discontent
Aggressive
Disapproved
Sad
Religious preference
What is your religious preference?
FURTHER COMMENTS
ANY FURTHER COMMENTS YOU WOULD LIKE TO SHARE WITH US?
Submit