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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