AM I A CANDIDATE?

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Am I a Candidate?


Medical History



SURGERIES

Have you ever had a blood transfusion?

All questions contained in this questionnaire are optional and will be kept strictly confidential.

Exercise
Diet

Are you dieting?

If yes, are you on a physician prescribed medical diet?
# of meals you eat in an average day? 3-4

Rank salt intake

Rank fat intake
Caffeine

Consumption

Number of cups / cans per day?
Alcohol

Do you drink alcohol?

If yes, what kind?

How many drinks per week?

Are you concerned about the amount you drink?

Have you considered stopping?

Have you ever experienced blackouts?

Are you prone to “binge” drinking?

Do you drive after drinking?
Tobacco

Do you use tobacco?


Cigarettes – pks./day









Drugs

Do you currently use recreational or street drugs?


Have you ever given yourself street drugs with a needle?

Sex

Are you sexually active?


If yes, are you trying for a pregnancy?



Women Only

Age at onset of menstruation

Date of last menstruation

Period every ___ days

Heavy periods, irregularity, spotting, pain, or discharge?

Number of pregnancies and Number of live births

Are you pregnant or breastfeeding?

Have you had a D&C, hysterectomy, or Cesarean?

Any urinary tract, bladder, or kidney infections within the last year?

Any blood in your urine?

Any problems with control of urination?

Any hot flashes or sweating at night?

Do you have menstrual tension, pain, swelling, irritability, etc.?

Did you recently have breast, lump or nipple discharge?

Date of last pap and rectal exam?
Men Only

Do you usually get up to urinate during the night?

If yes, # of times

Do you feel pain or burning with urination?

Any blood in your urine?

Do you feel burning discharge from penis?

Has the force of your urination decreased?

Do you have any problems emptying your bladder completely?

Any difficulty with erection or ejaculation?

Any testicle pain or swelling?

Date of last prostate exam?

FAMILY HEALTH HISTORY

Significant Health Problems