Medical Treatment Questionnaire

MEDICAL TREATMENT QUESTIONNAIRE (EXAMPLE)

DATE OF MEDICAL TREATMENT HEISEI YEAR MONTHãDAY
ADDLESS ãTEL
FULL NAME ã WEIGHT kg/TEMPERATURE ãâ
BIRTHDATE AGE ãã Name of person filling out form
PLEASE CIRCLE YOUR RESPONSES FOR THE FOLLOWING QUESTIONS:
âIS THERE ANYTHING THAT WOULD CAUSE YOU A RASH? MEDICINE: ãã FOOD:ãããOTHER:	YES	NO
âHAVE YOU EVER BEEN TOLD YOU HAVE ASTHMA?	YES	NO
âIS THERE ANYTHING THAT WOULD CAUSE YOU HIVES? MEDICINE: ãã FOOD:ãããOTHER:	YES	NO
âHAVE YOU EVER HAD A BAD REACTION TO PENICILLIN SHOTS OR PILLS?	YES	NO
âHAVE YOU EVER HAD ANY ADVERSE SIDE EFFECTS FROM ANY MEDICATION? ãNAME OF MEDICATION:	YES	NO
âARE YOU TAKING ANY OTHER MEDICATION AT THE PRESENT TIME?ããNAME OF MEDICATION:	YES	NO
âHAS YOUR CONDITION EVER BECOME WORSE WHILE TAKING ANY CERTAIN REMEDY? ãNAME OF REMEDY:	YES	NO
âHAVE YOU EVER BEEN TOLD BY A DOCTOR THAT YOU MAY HAVE A TENDECY TOWARD ANY SPECIAL PHYSICAL CONDITION?	YES	NO
âHAVE YOU EVER HAD A SERIOUS ILLNESS? (SURGERY OR HOSPITALIZATION) ILLNESS:	YES	NO
âIF YOU ARE A WOMAN, ARE YOU PREGNANT?	YES	NO
âYOUNG CHILDREN : IF YOUR CHILD HAS CONTRACTED ANY OF THE FOLLOWING ILLNESS, PLEASE CIRDLE THEM. MEASLES ãRUBELLA CHIKENPOXãMUMPS AUTOTOXEMIA

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