Life Extension Institute of S.A.
Mayo Clinic 9
14th Avenue, Constantia Kloof
 PO Box 5137, Weltevreden Park 1715
 011 475 1442
EXECUTIVE HEALTH CHECK
Diagnostic Clinic
PLEASE PRINT:
SURNAME …………………………………………………….. INITIALS ……………… TITLE ………….…..……..
FIRST NAMES….…………..……………………..…………………………………………………………………………
MARITAL STATUS ……………………………………………………………….. SEX .………………..….…………............
DATE OF BIRTH …………………..…………..….. AGE ………….... ID No ………....…..………….………….…
NATIONALITY ………..………….…………..……... OCCUPATION ……………........………..…….………………
HOME ADDRESS ………………..……………………………………………..………………..……………………..
COMPANY NAME AND ADDRESS ………………..…………………………………………………………..………..
……………………………………..…………………………(Cell No)………….………………………………....
TELEPHONE (HOME) …………………..…………………… (WORK) …..…………….…..…………………………
.
POSTAL ADDRESS FOR REPORT ………………..………………………………….…………….…………………..
………………………………………………………………..………e-mail address…………………………….…...
NAME OF PERSON/ COMPANY RESPONSIBLE FOR ACCOUNT ………………………………..……………………
……..…………………………………………….………………………… SIGNATURE ……………………………
POSTAL ADDRESS FOR ACCOUNT ………………………………..………….……………………………...…….…
…………………………………………….………………………………………..……………………………………...……
MEDICAL PRACTITIONER …………………………………………………………………..……………….…………
MEDICAL AID …….………………………………..………….…… NUMBER ……………………………………….
BEFORE YOUR EXAMINATION – Please enquire from your Medical Aid whether they would cover any portion of the
cost. Any arrangements for payment should be concluded by yourself.
We regret that the Life Extension Institute cannot be involved or accept responsibility in any way.
1
APPLICANT’S HISTORY QUESTIONNAIRE
NAME:…………………………………………..
Type of sport:
…………………………….………………………
Please tick the appropriate answer.
…………………………….………………………
…………………………………………………….
1.
1.01
1.02
1.03
RELEVANT PERSONAL HISTORY:
Are you :
Married
Single
Remarried
Divorced or separated
Widow or Widower
1
2
3
4
5
Have you any children?
None
None alive now
1 – 2 alive now
3 – 4 alive now
5 + alive now
1
2
3
4
5
Are they healthy?
Yes
No – give details:
1
2
1.08
Occupation : give percentage sedentary
1.09
Has weight been basically constant for
the past 1 year?
Yes
No – if so
a) Gained :
1 – 2 kg
3 – 5 kg
6 – 10 kg
Over 10 kg
Reason :
Overeating
Diminished exercise
No apparent reason/or any other
reason
b) Lost :
1 – 2 kg
3 – 5 kg
6 – 10 kg
Over 10 kg
………………………………………………..
………………………………………………..
………………………………………………..
1.04
1.05
What qualifications do you have?
Matric
+ Technical only
+ Professional but no university degree
+ University degree
Reason :
Dieting
Increased exercise
No apparent reason/or any other
reason
1
2
3
4
What is your religion?
1.10
………………………………………………..
1.06
1.07
How much time do you usually spend
gardening or doing around the house
activities?
Nil or less than 1 hour per week
1 - 2 hours per week
3 - 6 hours per week
4 - 10 hours per week
Over 10 hours per week
1
2
3
4
5
Do you now regularly take part in active
Sport, games, or other athletic pursuits:
No
1
Yes
2
1.11
1
Alcohol consumption
Teetotal
If no –
Beer
Wine
Spirit
%
1
2
1
2
3
4
1
2
3
1
2
3
4
1
2
3
1
2
3
4
a) Number of drinks per day:
1–2
3–6
more than 6
1
2
3
c) Number of drinks per week:
1–2
3–6
more than 6
1
2
3
Do you smoke at present?
No
1
1.12
Yes – if so
What do you smoke?
Cigarettes
Pipe
Cigars
No. of cigarettes per day:
1 – 10
11 – 20
21 – 30
31 – 40
Over 40
2
Light smoker
Medium smoker
Heavy smoker
1
2
3
Do you regularly take any medicine,
tablet or other drug or medicine?
No
Yes – if so
Name:
1
2
No
Yes – if so
1) Number alive:
1
2
3 or more
1
2
3
4
5
2) Healthy?
Yes
No – if so give details
2.01
………………………………………………...
3) Have any died?
No
Yes – if so give details
Number:
Age:
Cause:
1
2
1
2
…………………………………………………
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2.02
1
2
1
2
3
a) Father:
Is your father alive?
Yes – if so
Age:
If not healthy – reason?
1
………………………………………………….
………………………………………………….
1
2
………………………………………………….
………………………………………………..
Is your father deceased?
Yes – if so
Age at death:
Cause of death:
………………………………………………..
………………………………………………..
3) Have any died?
No
Yes – if so give details
Number :
Age:
Cause:
1
2
………………………………………………..
RELEVANT FAMILY HISTORY
Applicant:
Have you any brothers:
No
Yes – if so
1) Number alive:
1
2
3 or more
2) Healthy?
Yes
No – if so give details
1
2
3
………………………………………………..
…………………………………………………
2.
1
2
1
…………………………………………………
1
2
…………………………………………………
…………………………………………………
Grandfather – alive?
Yes
No – if so
Age at death:
Cause of death:
…………………………………………………
…………………………………………………
…………………………………………………
1
2
………………………………………………….
………………………………………………….
………………………………………………….
Have you any sisters?
Grandmother – alive?
2
Yes
No – if so
Age at death:
Cause of death:
1
2
Yes
No – if so
Age at death:
Cause of death:
1
2
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Father’s brothers:
None
Number alive:
Number deceased:
Age at death and cause:
Mother’s brothers:
None
Number alive:
Number deceased:
Age at death and cause:
1
1
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Father’s sisters:
None
Number alive:
Number deceased:
Age at death and cause:
Mother’s sisters:
None
Number alive:
Number deceased:
Age at death and cause:
1
1
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b) Mother:
Is your Mother alive?
Yes – if so
Age:
If not healthy – reason?
3.
3.01
1
………………………………………………….
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APPLICANT’S PERSONAL HEALTH
General Health.
Is your health at present good or
very good with no presenting
symptom?
Yes
No – if so
Specify symptoms or illness in
order of importance:
1
2
…………………………………………………
Is your mother deceased?
Yes – if so
Age at death:
Cause of death:
…………………………………………………
1
…………………………………………………
………………………………………………….
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3.02
…………………………………………………
Grandfather – alive?
Yes
No – if so
Age at death:
Cause of death:
1
2
Relevant Past History.
a) Operations?
No
Yes – if so specify nature of
Operation and year:
1
2
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Grandmother – alive?
b) Relevant past illness of
3
significance
Nil
Yes – if so specify nature of
Illness and year
A relatively minor thing
Fairly bad
Bad – if so specify
1
2
1
2
3
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3.03
Allergies:
No
Yes – if so specify
3.08
Do any of these statements fit you?
I am often discontented with life
1
I have difficulty getting on with other
people
2
I lack confidence in my ability to meet
the demands of my work
3
I have difficulty in reaching a decision 4
I find it difficult to disagree with people
in a friendly way
5
I would like my life to have more
social significance
6
I resent criticism
7
I have difficulty in exercising authority 8
None of these
9
3.09
Do you find your job (including being a
Housewife):
My work gives me a lot of satisfaction
I rather dislike my work
I would like to change my job
My job specification is too vague
1
2
…………………………………………………
…………………………………………………
…………………………………………………
3.04
Diet:
Very good
Good
Fair
Poor
Any specific diet – if so specify
1
2
3
4
5
………………………………………………..
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………………………………………………...
………………………………………………….
3.10
………………………………………………….
3.05
3.06
3.07
Have you any problem with sleeping?
No
1
Yes – specify
2
I have always been a bad sleeper
3
My sleep has got worse recently
4
I have difficulty in getting to sleep
5
I get to sleep all night but tend to wake
up unusually early
6
I wake up several times during the
night
7
Do you have any of the following
symptoms?
Irritability/bad temper
Rundown or lack of energy/unusual
tiredness or fatigue
Depression – feeling low or unusually
fed up
Unusually worried, anxious or tense
None of these
3.11
3.12
1
2
3
4
5
3.13
Is your problem –
4
I have too much responsibility
They do not give me enough
responsibility
The company is in a state of flux
(merger, takeover, etc)
None of these
Do you have any difficulty in handling
your financial affairs:
Not at all
Only a little
I managed financially but more
money would make a big difference
I have financial difficulties
I worry about money a lot
Now some questions about your home
life:
Do you live:
With your wife/husband
Alone
With friends
With parents
In a hotel or lodgings
If never married go to 3.13.
Do any of the following statements fit?
1
2
3
4
1
2
3
4
1
2
3
4
5
1
2
3
4
5
My marriage has not been as happy
as I would have liked
I get upset over family rows
I worry about my children or wife/
husband
My wife/husband worries about me
None of these
3.14
Is your worry about
Your wife’s/husband/s way of life
Your wife’s/husband/s health
Your children’s way of life
Your children’s health
Something else – if so specify
or your eyes, not corrected by glasses?
No
1
Yes
2
1
2
3
4
5
What kind of trouble do you have?
Dim vision
Fuzzy vision
Narrow field
Double vision
Red or weeping eyes
Glaucoma
Blind or lazy eye
Something else – if so specify
1
2
3
4
5
…………………………………………………
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3.15
…………………………………………………
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Do you have any medical problems that
we have not covered?
No
1
Yes – if so specify
2
6.01
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APPLICANT’S SYSTEMATIC HISTORY
Do you have any skin trouble or rash?
No
1
Yes – if so specify
2
………………………………………………..
………………………………………………...
…………………………………………………
6.02
…………………………………………………
Do you have any trouble with your nose
or sinuses?
No
1
Yes – only a blocked nose
2
Yes – something else – specify
3
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Treatment if any:
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5.02
1
2
3
4
5
………………………………………………..
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5.01
Do you have any problems with your
ears or hearing?
None
Hearing difficulty (deafness)
Running or infected ears
Buzzing noises in the ears
Something else – if so specify
………………………………………………..
………………………………………………….
4.
4.01
1
2
3
4
5
6
7
8
Do you wear glasses?
No, never
Yes, regularly
Yes, occasionally
Yes, but only for reading
Yes, but only for distant vision
Yes, contact lenses
6.03
1
2
3
4
5
6
Do you have difficulty with your vision
5
Do you have any soreness or other
trouble with your mouth or teeth?
Not recently
Yes, under treatment
Yes, not under treatment
I go to the dentist regularly
I go to the dentist rarely
1
2
3
4
5
6.04
6.05
Do you have any trouble with
hoarseness or other problems with
your voice?
No
Yes, hoarseness occasionally
Yes, hoarseness frequently
Yes, other speech problems
occasionally
Yes, other speech problems
frequently
Do you have any throat symptoms?
No
Yes, difficulty or pain in swallowing
Yes, frequent sore throats
Yes, tonsillitis
Yes, other symptoms – if so specify
or as if things are spinning around?
Never
Occasionally (less than once a
month)
More frequently or worse recently
Yes, it has been diagnosed by a
doctor as Meniere’s disease
Something else – if so specify
1
2
3
4
5
………………………………………………..
5
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………………………………………………...
1
2
3
4
5
…………………………………………………
7.04
………………………………………………..
Have you ever fainted?
Never
Very rarely or very long ago
Getting worse or more frequently
recently
Something else – if so specify
………………………………………………..
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Have you or have you ever had any
disease of the nervous system?
No
Yes – if so specify
3
4
………………………………………………..
1
2
………………………………………………..
7.05
………………………………………………..
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Have you had any of the following
nervous symptoms?
Do you get headaches?
Never
Occasionally (not more than once a
week)
More frequent or severe recently
Diagnosed by a doctor as migraine
Something else – if so specify
1
2
………………………………………………..
………………………………………………..
7.02
2
3
4
………………………………………………..
7.01
1
Have you ever had a convulsion, fit,
seizure or epilepsy?
Never
Only in infancy or early childhood
Yes and I am under medical
supervision
Not under medical supervision but no
attack in the last year
Yes in the last year but not under
medical supervision
1
2
3
4
5
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1
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2
3
4
5
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7.06
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Do you have any weakness, unusual
clumsiness, or paralysis of any part
of your body?
No
Yes – but it is under medical
supervision
Not under medical supervision, no
deterioration in the last year
Getting worse and not under medical
supervision
1
2
3
4
………………………………………………..
………………………………………………..
7.03
Do you have spells when you feel dizzy
6
7.07
Do you have any numbness, tingling
or loss of sensation over any part of
your body?
No
Yes
What part of your body is involved?
Arm or hand
Leg or foot
Face
Chest or abdomen
Buttocks or back
8.01
8.04
1
2
When do you get this?
On exertion
At night
Only during certain seasons like
Spring or Autumn
In damp or cold weather
At other times – specify
1
2
3
4
5
3
4
5
………………………………………………..
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Have you had any disease of the lungs
or respiratory system?
No
1
Yes – if so specify
2
8.05
Do you suffer from or have you ever
suffered from asthma?
No
Yes
1
2
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9.01
…………………………………………………
Do you have a cough now?
No
Yes, no phlegm
Yes, white or grey phlegm only
Yes, yellow or greenish phlegm
1
2
3
4
Do you have or have you ever had any
problems with your heart, blood
pressure or blood circulation?
No
1
Yes – if so specify
2
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9.02
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8.03
1
2
………………………………………………..
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8.02
Do you get short of breath walking with
people of your own age on level ground?
No
1
Yes – if so
2
Have you ever coughed up blood?
No
Yes
1
2
…………………………………………………
…………………………………………………
Have you ever hand any pain or
discomfort in your chest?
No
Yes, but not in the last year
Yes, on walking uphill or hurrying
Yes, on walking on the level at an
ordinary pace
At other times
1
2
3
4
5
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7
9.03
When you get this pain or
discomfort what do your do?
Stop
Slow down
Carry on at the same pace
have a –
Heart murmur
Any other heart disease not
mentioned
1
2
3
1
2
………………………………………………..
………………………………………………...
9.04
9.05
If you stand still or sit down does the
pain or discomfort –
Go away in 2 – 4 mins
Go away in 5 – 10 mins
Not necessarily get better
1
2
3
Where is this pain?
Centre of the chest
Right side of the chest
Left side of the chest
Left arm
Some other position
1
2
3
4
5
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9.09
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9.10
………………………………………………..
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9.06
Has a doctor told you the cause of this
pain?
Not consulted a doctor
Not told
Doctor did not know
Due to injury or rheumatic
condition (arthritis, fibrositis, etc)
Due to disease of the chest or lungs
Due to heart disease (angina,
coronary thrombosis)
Stress, tension, anxiety
Indigestion or other disease of the
stomach, bowel or gall bladder
Something else – if so specify
1
2
………………………………………………
10.01
4
5
6
7
Do you have or have you ever had any
disease or symptoms of your digestive
tract?
No
1
Yes – if so specify
2
………………………………………………..
8
9
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10.02
1
2
………………………………………………..
Do you suffer from indigestion, heartburn,
Excessive belching or wind or other ‘stomach’
Trouble?
Never
1
Occasionally
2
Bad in the past but all right now
3
More often than this
4
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9.08
4
……………………………………………..
1
2
3
………………………………………………..
Have you had any treatment for your
pain?
No
Yes – if so specify
Do you have high blood pressure?
No
Yes – if so specify
a) When diagnosed
b) Treatment
1
2
3
……………………………………………..
………………………………………………..
9.07
Do you sometimes notice your heart
beating in an unusual manner?
No, it always seems about normal
Yes, it sometimes beats irregularly
Yes, it sometimes beats very slowly
Yes, it sometimes beats very rapidly
even without exercise
Has a doctor ever told you that you
8
10.03
10.04
10.05
Is this indigestion or pain
Worse at night
Relieved by food
Made worse by food
Relieved by alkaline medicines
(eg Rennies, Nulacin, Aludrox)
None of these
Is this indigestion trouble
Unchanged over the last few months
Getting better on your doctor’s
treatment
Getting better on your own treatment
of no treatment
Getting worse despite doctor’s
treatment
Getting worse – not under your
doctor
Has your doctor told you the cause
of this trouble?
No
Gastric ulcer
Duodenal ulcer
Some other sort of ulcer
Gastritis
Hiatus hernia
Gall bladder disease or stones
Disease of the oesophagus (gullet)
Something else – if so specify
10.08
1
2
3
4
5
10.09
1
2
3
4
Have you ever vomited blood?
No
Yes
1
2
3
4
5
6
7
8
9
10.11
Do you have piles (haemorrhoids)
No
Not now, but I did have
I think so
Yes, under medical supervision
Yes, not under medical supervision
1
2
3
4
5
Do you have any of the following
symptoms in or around your anus
(back passage)?
None
Bleeding
Itching
Pain
Discharge
1
2
3
4
5
10.12
1
2
3
………………………………………………..
1
2
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11.01
………………………………………………...
Have you ever had jaundice (gone
gone yellow?
No
Not sure
Yes, due to infective hepatitis
Yes, due to gall stones or
cholecystitis (infection of the gall
bladder) or other disease of the
gall bladder
Yes, something else or cause not
Known
5
Have you in the past year passed stools
that were
Black or tar-like
1
Red or blood-streaked
2
Had a lot of mucus (slime) in them
3
Very light, almost white in colour
4
Haven’t notices anything unusual
5
………………………………………………..
10.07
1
2
3
4
10.10
………………………………………………..
Do you vomit (are you sick)
Never
Very occasionally (less than once
a month)
More than once a month
Has there been any change in your
bowel habit in the last few months?
No
Not sure
Looser than usual
More constipated than usual
Periods of looseness and
constipation
1
2
3
4
5
5
………………………………………………..
10.06
How frequently do you have a bowel
movement?
Once a day
Two or three times a day
Four or more times a day
About every other day
Less often than this
Have you had any disease or problems
with your bladder or kidneys?
No
1
Yes – if so specify
2
…………………………………………………
1
2
3
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4
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5
11.02
9
Have you ever had a bladder
infection (cystitis) or kidney infection
(pyelitis)?
No
Yes – once
Yes – more than once
Pain, discomfort or burning
sensation when passing urine
Difficulty in holding your urine
Blood in the urine (red or pink urine)
11.03
11.04
11.05
12.03
1
2
3
4
5
6
Do you have any difficulty in passing
urine?
None
Some dribbling only
Some difficulty in starting only
(hesitancy)
Both of these
I have had a complete stoppage
(inability) to pass urine
13.01
13.02
1
2
3
4
5
13.03
1
2
3
4
5
1
2
3
4
5
Has there been any change in size or
pain in your testicles in the past year?
None
One or both getting larger
One or both getting smaller
Some other lump present
Something else – if so specify
1
2
3
4
5
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SECTION 14 – WOMEN ONLY
(Men to Section 15)
1
2
3
4
5
14.01
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………………………………………………..
………………………………………………..
Have you had a test for AIDS?
No
Yes
Have you had any difficulty having
erections?
Never
In the past but all right now
Never very good
Getting slowly worse
Suddenly deteriorated
………………………………………………..
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12.02
1
2
3
4
………………………………………………..
…………………………………………………
Have you ever had any form of
venereal disease (VD)?
No
Yes – don’t’ know what
Yes – Gonorrhoea (Clap)
Yes – Syphilis
Yes – some other
Have you had any of the following
conditions?
Enlarged prostate
Cancer of the prostate
Prostatitis
None of these
………………………………………………..
…………………………………………………
12.01
1
2
3
4
5
SECTION 13 – MEN ONLY
(Women to Section 14)
Have you ever had any of the following?
Stone or renal colic
1
Bilharzia
2
Nephritis or nephrosis
(nephrotic syndrome)
3
Do you usually get up at night to pass
urine?
No
Most nights
Once every night
2-3 times every night
4 or more times every night
Is your libido (sexual desire)
About average
Never been very great
More than most
Decreasing recently
Increasing recently
How old were you when your periods
Started?
Under 13
13 – 14
15 – 16
17 or over
Never had one
1
2
3
4
5
When was your last period?
1
2
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14.02
10
Are your periods normally
Very regular
Usually regular
Sometimes irregular
Very irregular
1
2
3
4
No
Yes – if so specify
Natural menopause (change of
life)
After surgery or x-ray treatment
After the last baby
Some other reason
………………………………………………..
………………………………………………..
………………………………………………..
14.03
How long do they last?
1 – 3 days
4 – 7 days
Over 7 days
They’re getting longer
They’re getting shorter
14.05
14.06
Are you pregnant?
Yes
No
Are you generally tense or nervous
before your period start?
Yes, usually
Yes, occasionally
No, not often
No, hardly ever
Have you had any bleeding between
periods in the last year?
Definitely not
Yes – if so specify
…………………………………………………
…………………………………………………
1
2
3
4
5
…………………………………………………
…………………………………………………
1
2
1
2
…………………………………………………
1
2
3
4
…………………………………………………
…………………………………………………
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14.10
…………………………………………………
Have you had an unusual vaginal
discharge?
No
Yes, getting better
Yes, not getting better despite
treatment
Yes, not getting better, not having
treatment
…………………………………………………
…………………………………………………
…………………………………………………
…………………………………………………
…………………………………………………
…………………………………………………
1
2
………………………………………………..
1
2
3
4
…………………………………………………
Do you have any pain in your back, pelvis
or abdomen with your periods?
No
1
Yes – if so specify
2
14.11
………………………………………………..
………………………………………………..
………………………………………………..
Do you have any bleeding after
sexual intercourse?
No
None in the last year
Sometimes
Frequently
1
2
3
4
………………………………………………….
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14.08
Have you had any bleeding since your
periods stopped?
Not applicable
Yes – if so specify
…………………………………………………
………………………………………………..
14.07
2
3
4
5
…………………………………………………
14.09
14.04
1
………………………………………………….
14.12
Have you stopped menstruation?
11
Do you experience pain during
intercourse?
No
Yes
Sometimes
Ovarian cysts
Endometriosis
No, none of these
1
2
3
14.18
………………………………………………..
………………………………………………..
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14.13
Do you have any sexual problem with
which you would like help?
No
Yes – if so specify
14.19
1
2
…………………………………………………
…………………………………………………
…………………………………………………
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14.20
…………………………………………………
14.14
Have you ever had a cervical (Pap)
smear done?
Never
Yes
Date of last smear:
1
2
………………………………………………..
14.15
Was the result
Normal (negative)
Abnormal
14.21
1
2
…………………………………………………
…………………………………………………
…………………………………………………
14.16
14.17
Have you ever regularly practised any
contraceptive technique?
No
Yes, on the Pill now
Yes, have an IUD now (loop or coil)
Yes, was on the Pill but not now
Yes, something else
Have you ever had any of the following
conditions?
Miscarriage or abortion
Caesarean section
Ectopic (tubal) pregnancy
Raised blood pressure, albumen
in the urine, swelling of the ankles
during pregnancy for which you had
to rest or have treatment (toxaemia)
Cystitis or pyelitis (infections of
Kidney or bladder) during
Pregnancy
Uterine fibroids
Uterine fibroids
Do you ever have pain in your breasts?
No
Yes, left one only
Yes, right one only
Yes, both breasts
Is this pain
Related fairly regularly to your
periods and not getting worse
Unchanged for several months but
not related to periods
Getting better
Getting slowly worse
Getting much worse recently
Do you have one or more lumps in
your breasts?
Definitely not
I don’t think so
Yes, there are several lumpy areas
Yes, both breasts about the same
Yes, one side only or one side much
worse
How long have you had this condition?
It has been present for years, no
recent change
It comes and goes with my periods
It has been present for some months,
no recent change
Only noticed it recently, or recently
getting bigger, harder or painful
7
8
9
1
2
3
4
1
2
3
4
5
1
2
3
4
5
1
2
3
4
………………………………………………..
………………………………………………..
………………………………………………..
1
2
3
4
5
…………………………………………………
14.22
1
2
3
Do you have any of the following
symptoms with your breasts?
Discharge from the nipple
Bleeding from the nipple
Puckering of the skin of the breast
Recent retraction of the nipple
None of these
4
5
6
6
Section 15
12
1
2
3
4
5
15.01
Any other – if so specify
Have you had any disease or problems
with your blood?
No
1
Yes – if so specify
2
………………………………………………..
17.03
………………………………………………..
………………………………………………..
15.02
16.01
Have you had any of the following?
Anaemia
A bleeding disease or abnormal
blood cells
Too many blood cells
None of these
Have you ever been told by a doctor
that you had trouble with your
thyroid gland?
No
Yes, over activity
Yes, under activity
Yes, just an enlargement or lump
Yes, something else
…………………………………………………
2
3
4
18.01
1
2
3
4
5
19.01
…………………………………………………
16.03
16.04
Are you usually very thirsty and
continually drink very large amounts of
water or other fluids?
No
1
Yes, always like that
2
Yes, more thirsty recently
3
Are you a diabetic?
Not as far as I know
Yes, on diet only
Yes, taking pills
Yes, taking injections of insulin
Do you get any swelling of your ankles?
No
One side only
Only in hot weather or after
standing a long time
Most evenings
All the time
17.02
19.02
1
2
3
4
Have you had any disease or problem
not already mentioned apart from
children diseases, flu or colds?
No
Yes – if so specify
1
2
3
4
5
1
2
Have you had any growth or tumour
you have not already mentioned?
No
Yes – if so specify
1
2
…………………………………………………
…………………………………………………
19.03
1
2
Any inherited disease or problem?
No
Yes – if so specify
1
2
…………………………………………………
3
4
5
…………………………………………………
19.04
Do you have swelling, pain or other
trouble in any of your joints, in the limbs
or back?
No
1
Yes – if so specify
2
Have you had any of the following?
Disc problem
Rheumatoid arthritis
Osteoarthritis
Gout
Fibrositis
Have you ever had varicose veins?
No
Yes, but all right since treatment
Yes, but never a problem
Yes, but no serious complications
Yes, I also have or had ulcers or
phlebitis
………………………………………………..
………………………………………………..
17.01
Injuries:
Have you had any injury which has left
a permanent disability?
No
1
Yes – if so specify
2
…………………………………………………
1
…………………………………………………
16.02
6
Have you any physical deformity?
No
Yes – if so specify
1
2
…………………………………………………
19.05
1
2
3
4
5
Are you at present on any form of
medication?
No
Yes – if so specify
1
2
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13