Medical Assessment Questionnaire

Name

Date of birth

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Telephone

Mobile (optional)

Email

Have you ever suffered from heart or lung problems?
YesNoX

Have you ever suffered from liver failure?
YesNoX

Have you ever suffered from a head injury?
YesNoX

Have you ever suffered from seizures or fits?
YesNoX

Have you ever suffered from Asthma?
YesNoX

Have you ever suffered from blood pressure problems?
YesNoX

Have you ever suffered from balance problems?
YesNoX

Have you ever suffered from Diabetes?
YesNoX

Have you ever suffered from pancreas disorders?
YesNoX

Have you ever had problems of swelling?
(E.g. in the stomach or feet)
YesNoX

Are you allergic to any medication?
YesNoX

Have you ever suffered from any mental health problems?
YesNoX

Have you ever been sectioned under the Mental Health Act?
YesNoX

Have you ever attempted to harm yourself in any way, for example, taken any overdoses, cutting yourself etc.?
YesNoX

Have you ever deliberately attempted to kill yourself?
YesNoX

Are you suffering from any medical conditions at the moment?
YesNoX

Are you currently taking any medication?
YesNoX

Have you had a blood test in the last four weeks about which we may contact your doctor?
YesNoX

Do you currently use any street drugs, for example, heroin, cocaine, cannabis etc.?
YesNoX

Have you ever undertaken a "detox" for alcohol or drug problems in the past?
YesNoX

When did you last see your doctor?
—Please choose an option—This WeekLast WeekThis MonthLast Month3-6 MonthNot recently

Are you currently being seen by someone from a community drug or alcohol service?
YesNoX

Is the above information correct at the time of completing this assessment?
Please confirm by printing your name which will constitute as a signature and check the box so that you have read our Service Agreement and that you agree to the terms and conditions it sets out