Body Anamnesis Form | Dr. Saad M. Halimi Rehabilitation Center

General Info.

Name

Date of Birth

Gender

Male

Female

Address

City

Phone / Mobile

Date of Thermo

Referred By

Habits

Smoking

Yes

How much per day

Only Smoking in the past

Yes

Drinking alcohol

Yes

How much per day

How much coffee do you drink per day

Medical Problems

Short description of medical problems

Since when

Something happened the problem exists? Or do you know the cause of the problem?

Back

Diseases

Do you have or have had any of the following diseases?

Diabetes

Varices

Thrombosis

High blood pressure

Heart attack

Heart disease

Stroke (CVA)

Hypothyroidism

Hyperthyroidism

Breast tumor

Gastritis

Hepatitis

Arthroses

Options

Rheumatism

positive blood test

Yes

Cancer

Yes

Type

Location

Stage

Allergies

Respiratory (asthma)

Alimentary

Contact (Skin)

Symptoms

Options

Itching

Difficulty in sleeping

Diarrhea

Constipation

Dizziness

Forgetfulness

Abdominal distention after meal

Bleeding

Numbness

Hands

Feet

Other Location

Tingling

Hands

Feet

Other Location

Options

Swelling of the ankles

Back

Family History

Options

History of cancer in the family

Type of Cancer

Family Relationship

Other diseases in the family (such as diabetes, heart, stroke,allergies ect.)

Surgeries

Mark the surgeries you have had:

Options

Vertebral column

Heart

Kidney

Joints

Herniated disc

Carpal tunnel syndrome

Caesarean section

Gallbladder

Thyroid

Varices

Plastic Surgery

Eyes

Appendix

Ovarian

Breast

Uterus

Other/Specify

Other

Scheduled Surgeries

Back

Other Info.

Do you have at this moment

Fever

Infection

Have you had the flu, a cold, or a lot of coughing in the last 3 weeks?

Yes

Have you had a recent trauma in the last 3 months (a fall, sports, injury, car accident, dental work, surgery, ect.)?

Yes

Date of last menstrual period

Name

med1

med2

med3

med4

med5

Dose

dose1

dose2

dose3

dose4

dose5

Regularity

reg1

reg2

reg3

reg4

reg5

How long have you been taking it

dur1

dur2

dur3

dur4

dur5

Exams

Mark what you have had and describe the reason of this exam:

X ray

X ray Text

Ultrasound / Echography

Ultrasound / Echography Text

MRI

MRI Text

CT Scan

CT Scan Text

EMG

EMG Text

Scintigraphy

Scintigraphy Text

Endoscopy / Colonoscopy

Endoscopy / Colonoscopy Text

Mammography

Mammography Text

Others

Do you use

Crutches

Wheelchair

Mark the intensity of pain at this moment

Zero is No pain, 10 is the Worst pain

Submit

Thank you!

We will contact you soon.

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