1
Step 1
Personal details
2
Step 2
Social & Family
3
Step 3
Medical History
4
Step 4
Medical History
5
Step 5
Medical History
6
Step 6
Medical History

Union Quay Medical Centre

Health Screening Questionnaire

Name *

Todays Date *

Date of Birth *

Address Form *

Address 1

Address 2

City

Country

Marital Status *

Single

Married

Other

Sex *

Male

Female

Phone *

Email *

Confirm Email *

Family Doctor

Step 2

Social History

Do you smoke ? *

Yes

Did you ever smoke ? *

Yes

Cigarettes/cigars per day *

When did you stop ?

Do you drink alcohol ? *

Yes

No. of units per week ? *

(Note: 1 unit alcohol = 1 glass wine, 1/2 pint beer, 1 shot spirits)

Do you exercise ? *

Yes

Sessions per week ? *

Family History

1.Fathers Age

2.Mothers Age

3.Sibling 1 Age

4.Sibling 2 Age

5.Child 1 Age

6.Child 2 Age

7.Child 3 Age

If living - current health

Father Details

Mother Details

Sibling 1 Details

Sibling 2 Details

Child 1 Details

Child 2 Details

Child 3 Details

If deceased - cause of death

Father Details

Mother Details

Sibling 1 Details

Sibling 2 Details

Child 1 Details

Child 2 Details

Child 3 Details

Medical History

Part 1

1. Are you currently under medical care: *

Yes

If yes to 1, Medical details with dates

2. Have you been in hospital otherwise ? *

Yes

If yes to 2, hospital details with dates

3. Have you had any operations ? *

Yes

If yes to 3, operation details with dates

4. Have you undergone X-Rays or tests ? *

Yes

If yes to 4, X-ray/test details with dates

5. Are you taking any Medications ? *

Yes

If yes to 5, medication details with dates

Do you suffer from or have you ever had?

A. Fainting - Dizziness - Fits - Blackouts - Epilepsy *

Yes

If yes to A. Details with dates

B. A fear of height or open spaces (agoraphobia) *

Yes

If yes to B. Details with dates

C. A fear of confined spaces (claustrophobia) *

Yes

If yes to C. Details with dates

D. Recurrent headaches or Migraine *

Yes

If yes to D. Details with dates

E. Mental illness or nervous trouble *

Yes

If yes to E. Details with dates

F. Stress related illness *

Yes

If yes to F. Details with dates

Medical History

Part 2

Do you suffer from or have you ever had?

G. Anxiety or depression *

Yes

If yes to G, details with dates

H. Eye disorder or disturbance of vision *

Yes

If yes to H, details with dates

I. Ear trouble, infections or deafness *

Yes

If yes to I, details with dates

J. Did you ever work in a noisy environment *

Yes

If yes to J, details with dates

K. Hay Fever or Sinusitis *

Yes

If yes to K, details with dates

L. Asthma *

Yes

If yes to L, details with dates

M. Bronchitis, Pneumonia or Pleurisy *

Yes

If yes to M, details with dates

N. Chronic cough *

Yes

If yes to N, details with dates

O. Shortness of breath or wheezing *

Yes

If yes to O, details with dates

P. Tuberculosis *

Yes

If yes to P, details with dates

Q. Any other chest compaint ? *

Yes

If yes to Q, details with dates

R. High blood pressure *

Yes

If yes to R, details with dates

Medical History

Part 3

Do you suffer from or have you ever had?

S. Chest pain, tightness or palpitations *

Yes

If yes to S, details with dates

T. Rheumatic Fever *

Yes

If yes to T, details with dates

U. Any other heart disease or disorder ? *

Yes

If yes to U, details with dates

V. Varicose vein trouble or ankle swelling *

Yes

If yes to V, details with dates

W. Anaemia *

Yes

If yes to W, details with dates

X. Dermatitis, eczema or skin allergy *

Yes

If yes to X, details with dates

Y. Psoriasis or other skin problem *

Yes

If yes to Y, details with dates

Z. Difficulty with your appetite *

Yes

If yes to Z, details with dates

1. Has there been any recent change in your weight? *

Yes

If yes to 1, details with dates

2. Stomach trouble, indigestion/heartburn or ulcers *

Yes

If yes to 2, details with dates

3. Jaundice or hepatitis *

Yes

If yes to 3, details with dates

4. Chronic diarrhoea or constipation *

Yes

If yes to 4, details with dates

Medical History

Part 4

Do you suffer from or have you ever had?

5. Urine or kidney trouble *

Yes

If yes to 5, details with dates

6. Diabetes, thyroid disease or other glandular disorder *

Yes

If yes to 6, details with dates

7. Back or neck trouble *

Yes

If yes to 7, details with dates

8. Rheumatism, tendonitis or other joint trouble *

Yes

If yes to 8, details with dates

9. Uterine, ovarian or menstrual trouble *

Yes

If yes to 9, details with dates

10. Cancer or benign tumours or cysts *

Yes

If yes to 10, details with dates

11. Any other significant medical condition *

Yes

If yes to 11, details with dates

12. Are you allergic to any drugs or chemicals *

Yes

If yes to 12, details with dates

13. Have you been off work in the last 2 years because of illness or injury? *

Yes

If yes to 13, details with dates

14. Have you ever had to give up a job for health reasons or injury? *

Yes

If yes to 14, details with dates

15. Have you ever had pain or discomfort when bending or lifting? *

Yes

If yes to 15, details with dates

16. Do you ever get aches in your neck or shoulders? *

Yes

If yes to 16, details with dates

17. Have you ever had a compensation claim against an employer because of an accident or ill health? *

Yes

If yes to 17, details with dates

DECLARATION

I hereby certify that I voluntarily completed this questionnaire. The answers to these questions are accurate to the best of my knowledge.

Signature *

Date Picker *

I agree to the Privacy Policy

Form Submitted Successfully!

We will contact you as soon as possible.

Phone: +353 21 431 0311

Email: info@uqmc.ie

Mon-Fri: 8:30AM - 6:00PM Sat: 9AM - 1PM

Health Screening Questionnaire

Union Quay Medical Centre

Step 2

Social History

Family History

Medical History

Medical History

Medical History

Medical History

Form Submitted Successfully!

About Us

Parking & Location

Useful Links

Phone: +353 21 431 0311

Email: info@uqmc.ie

Mon-Fri: 8:30AM - 6:00PM Sat: 9AM - 1PM

Union Quay Medical Centre

Step 2

Social History

Family History

Medical History

Medical History

Medical History

Medical History

Form Submitted Successfully!

About Us

Parking & Location

Useful Links

APPOINTMENTS