Addiction Treatment Facility

Client Medical Questionnaire

Please fill out every field. If a field does not apply, please fill in with N/A.

Client full name

Date of birth

Email address

Medical history

Please answer the following questions on your past and present medical history by ticking Yes or No.

Have you ever had or do you currently have:

Asthma, or wheezing with breathing, or wheezing with exercise?
YesNo

Frequent or severe attacks of hayfever or allergy?
YesNo

Frequent colds, sinusitis or bronchitis?
YesNo

Any form of lung disease?
YesNo

Pneumothorax (collapsed lung)?
YesNo

Other chest disease or chest surgery?
YesNo

Behavioural health, mental or psychological problems (diagnosis of mental illness, treated for depression/anxiety etc)?
YesNo

Epilepsy, seizures, convulsions, or take medications to prevent them?
YesNo

Recurring complicated migraine headaches or take medications to prevent them?
YesNo

Blackouts or fainting (full/partial loss of consciousness)?
YesNo

Frequent or severe suffering from motion sickness (seasick, carsick)?
YesNo

Dysentery or dehydration requiring medical intervention?
YesNo

Head injury with loss of consciousness in the past five years?
YesNo

Recurrent back problems?
YesNo

Back or spinal surgery?
YesNo

Diabetes?
YesNo

Back, arm or leg problems following surgery, injury or fracture?
YesNo

High blood pressure, or take medicine to control blood pressure?
YesNo

Heart disease?
YesNo

Heart attack?
YesNo

Angina, heart surgery or blood vessel surgery?
YesNo

Raised cholesterol level?
YesNo

Bleeding or other blood disorders?
YesNo

Hernia?
YesNo

Ulcers or ulcer surgery?
YesNo

Do you currently smoke tobacco?
YesNo

Could you be pregnant, or are you attempting to become pregnant?
YesNo

Do you have any allergies? (Please specify below)

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)?
YesNo

Do you require any walking aids?
YesNo

Are you able to climb a flight of stairs?
YesNo

Are you able to take a bath without assistance?
YesNo

Are you able to take a shower without assistance?
YesNo

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:

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

Please tell us anything else you feel we should know

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