For the following questions please indicate all that apply. If you answer YES to any question please supply BRIEF details in the text box. Don't worry if you are unsure about any of the questions; your doctor will review the questionnaire with you during your consultation.
1. Have you ever had an MRI scan, CT scan or X-ray in the past?
*
2. Do you have any Medical Investigations, either ongoing or pending? *
3. Are you fitted with a pacemaker and / or any other medical implants? *
4. Are you fitted with any artificial limbs or joints? *
5. Are you fitted with any removable dental work? *
6. Any possibility that small metal fragments may have entered the eyes through an accident or other cause? *
7. What was the date of your last menstrual period? (if applicable)*
8. Are you pregnant? (if applicable) *
9. Do you suffer claustrophobia? (although the vast majority of people are fine, some people may find the MRI scanner restrictive) *
CARDIO-RESPIRATORY
Please answer the following questions regarding your cardio-respiratory health:
10. Have you experienced chest pain during physical activity or while at rest?
*
11. Have you ever had a heart attack or undergone heart surgery? *
12. Do you experience palpitations (irregular or rapid heartbeats)? *
13. Have you been diagnosed with high blood pressure and / or experienced breathlessness? *
14. Do you have a persistent cough and / or have you ever coughed up blood? *
15. Do you have a history of tuberculosis (TB) and / or asthma ? *
16. Do you have a history of any lung diseases and / or have you been exposed to asbestos? *
17. Are you a smoker? Please answer YES or NO. If YES, please specify how long you have been smoking and the quantity smoked (e.g., number of cigarettes per day).*
18. Have you used illicit drugs?*
GASTROINTESTINAL
Please answer the following questions regarding your gastro-intestinal health:
19. Have you experienced * abdominal pain * bloating * changes in bowel habit ?*
20. Do you have any dietary restrictions?
*
NEUROLOGICAL
Have you experienced any of the following neurological symptoms? (Please list all that apply)
21. * Fits, faints, or unexplained loss of consciousness
* Persistent headache
* Dizziness
*
22. * Visual disturbance
* Hearing loss
* Head injury
* Stroke or mini-stroke (TIA)*
METABOLIC
Do you have any of the following metabolic conditions? (Please list all that apply)
23. Diabetes *
Thyroid problems *
Hormonal disturbance *
Raised cholesterol*
24. Do you consume alcohol, and if so how many units per week approximately?*
MUSCULOSKELETAL
Do you have any of the following musculoskeletal issues? (Please list all that apply)
25. * Joint or limb problems
* Mobility restrictions*
26. Please provide approximate dates and a brief description of any surgeries.*
27. Have you ever been diagnosed with a serious illness, cancer, or benign tumours, and have you experienced any recent unexplained weight changes? Please list all that apply.*
FAMILY HISTORY (IMMEDIATE RELATIVES) 28. Do any of your immediate relatives have a history of heart disease, stroke, bowel cancer, prostate cancer, lung cancer, breast cancer, or gynaecological cancers (such as uterine, cervical, or ovarian cancer)? Please list all that apply.*
29. Do you have any history of mental health problems or have you received any treatments related to mental health?*
30. Do you have any allergies to medications, food, iodine-based products, or other substances? Have you ever experienced anaphylaxis or been advised to carry an Epipen? Please list all that apply.*
31. Please provide a list of all current medications you are taking, including over-the-counter medications and supplements.*
32. Have you previously visited ProVigilant?*
33. How did you learn about ProVigilant? Please provide specific examples.*
34. Please indicate which health screening package you are interested in, either the Essential, Enhanced or Comprehensive, or are you interested in a Wellness package?*
Thank you for completing the questionnaire. Please review your answers to ensure accuracy. Once verified, kindly digitally sign and date the form, then press submit. Upon receipt, a representative from ProVigilant will be in touch to arrange an appointment.
Signature - Please add your electronic signature using your mouse or trackpad*
