A Random Image

Client Medical Questionnaire

Your details

Client details

Medical history

Please answer the following questions on your past and present medical history.

Have you ever had or do you currently have:

Asthma, or wheezing with breathing, or wheezing with exercise?  Yes No
Frequent or severe attacks of hayfever or allergy?  Yes No
Frequent colds, sinusitis or bronchitis?  Yes No
Any form of lung disease?  Yes No
Pneumothorax (collapsed lung)?  Yes No
Other chest disease or chest surgery?  Yes No
Behavioural health, mental or psychological problems (diagnosis of mental illness, treated for depression/anxiety etc)?  Yes No
Epilepsy, seizures, convulsions, or take medications to prevent them?  Yes No
Recurring complicated migraine headaches or take medications to prevent them?  Yes No
Blackouts or fainting (full/partial loss of consciousness)?  Yes No
Frequent or severe suffering from motion sickness (seasick, carsick)?  Yes No
Dysentery or dehydration requiring medical intervention?  Yes No
Head injury with loss of consciousness in the past five years?  Yes No
Recurrent back problems?  Yes No
Back or spinal surgery?  Yes No
Diabetes?  Yes No
Back, arm or leg problems following surgery, injury or fracture?  Yes No
High blood pressure, or take medicine to control blood pressure?  Yes No
Heart disease?  Yes No
Heart attack?  Yes No
Angina, heart surgery or blood vessel surgery?  Yes No
Raised cholesterol level?  Yes No
Bleeding or other blood disorders?  Yes No
Hernia?  Yes No
Ulcers or ulcer surgery?  Yes No
Do you currently smoke tobacco?  Yes No
Could you be pregnant, or are you attempting to become pregnant?  Yes No
Do you have any allergies? (Please specify below)  Yes No

Please tell us about your mobility and fitness:

Are you able to perform moderate exercise (for example walking 1.6 km/one mile within 12 minutes)?  Yes No
Do you require any walking aids?  Yes No
Are you able to climb a flight of stairs?  Yes No
Are you able to take a bath without assistance?  Yes No
Are you able to take a shower without assistance?  Yes No

You are applying to Ledgehill Treatment and Recovery Centre to participate in a holistic residential addictions treatment program. The program entails moderate daily physical activity, therapy and psychoeducational programming. We require that all participants be effectively medically managed for all physical and mental health conditions prior to attending the LTRC program. If it is necessary for you to receive medical consultation or treatment whilst attending LTRC the costs incurred must be met by yourself or financial sponsor.

Prescribed medications

Please indicate all currently prescribed medications, the doses and the frequency of administration:
(write 'none' if you do not currently take any prescribed medication)

Please ensure that you bring an adequate supply of medications for the duration of your stay at Ledgehill.

Other information

Please tell us anything else you feel we should know:


Client Medical Statement

I have no medical conditions that are unmanaged or contra-indicatory to residential addictions treatment.

Please note that you will be asked to sign this form on admission to Ledgehill.


Return to admissions page.




Email us

Your name

Your email (required)

Your message

What our clients say…

"Ledgehill is a very nice place with very good people that helped me in taking the time to examine my life and recognize apsects of it that weren't working and why. I left with much greater clarity, self awareness and sense of purpose. This has allowed me to shed negative habits while directing myself more in a life style I want to live."

- S, Antigua, West Indies, Dec 2010

"I recently completed the program at Ledgehill and found the staff from kitchen to counsellors very supportive, knowledgeable and caring, the location and privacy is all first class, it was time and money well spent, the learning and tools are all there, it’s up to me from here on in. It was a great experience."

- J, Aug 2010


"Ledgehill gave me the unique and very eye opening experience of examining my life (...) Ledgehill taught me that I am not giving anything up, but in fact I'm gaining everything. I look forward to a new and clear beginning. A life that I should have had years ago."

- T, Aug 2010


"You did so much for me. You continue to help every day with all I have taken away with me both in counseling and the feeling of belonging... my extended family."

- J, Jan 2010


"Ledgehill is a great place. (...) was so blessed to be able to be there with you guys and to be able to learn who he really is"

- M, Jan 2010