Please answer the following questions by X the most appropriate answer
1. Have you been treated with antibiotics?
2. Have you ever had any problems with yeast infections?
3. Do you eat or crave a lot of sweet foods?
4. Do you have a problem with food allergies?
5. Have you suffered from any food poisoning?
6. Do you or have you consumed alcohol on regular basis?
7. Have you ever taken the drugs Tagamet or Zantac?
8. Do you take aspirin, panadeine or other pain killers?
9. Do you take any other types of drugs regularly?
10. Are you often in contact with organic chemicals?
(i.e. insecticides, herbicides, petro chemicals etc)
11. Do you react to strong perfumes, car exhaust, etc?
12. Do you or have you ever smoked or used tobacco products?
13. Are you exposed to passive cigarette smoke?
14. Do you consume beverages/food containing caffeine?
LIVER DETOXIFICATION TEST (LDT) SCREENING QUESTIONS
A certain percentage of patients will experience adverse reactions during the LTD. The reactions include, butare not limited to: shakiness, headaches, nausea, palpitations, light-headedness and sweating. The followingquestions will help isolate those patients who may experience these types of reactions.
1. Do you react when you consume caffeine-containing beverages or food?
2. Are you sensitive to food additives such as M.S.G.?
3. Do you have a history of liver problems? If yes please describe the type of problem:
4. Are you currently taking any drugs? If yes, list below:
DR JAA’S MEDICAL HEALTH
■ Dr. Ping Jaa MBBS(UQ), DRANZCOG, FRACGP, FACNEM
Suite 6, Riverwalk One, 140 Robina Town Centre Drive, Robina Qld 4226
■ Dr. David Jaa MBBS(UQ), B.Med. Sc.(UQ), GDPM(Syd.U), Master of PM(Syd.U), FACNEM, FACPM(Syd.U) Phone: (07) 5562 2088 Fax: (07) 5562 2085
■ Dr. Eugene Jaa MBBS(UQ), DRCOG, FAMAC, Dip Obst.(Auck), MRACGP GENERAL SCREENING QUESTIONNAIRE
Rate each of the following symptoms based upon your health profile for the past 30 days. This is to assist your Doctor to assess your conditions.
0 = Never or almost never have the symptom1 = Occasionally have it, effect is not severe2 = Occasionally have it, effect is severe3 = Frequently have it, effect is not severe4 = Frequently have it, effect is severeX = Not sure
DiarrhoeaConstipationBloated FeelingBelching or passing gasHeart burnIntestinal / Stomach Pain
Itchy EarsEar aches, ear infectionsDrainage from earRinging in ears, hearing loss
Mood SwingsAnxiety, fear or nervousnessAnger, irritability, or aggressivenessDepression
Watery or itchy eyesSwollen, reddened or sticky eyelidsBags or dark circles under eyesBlurred or tunnel vision(does not include near or far-sightedness)
Irregular or skipped heartbeatRapid or pounding heartbeatChest pain
ArthritisStiffness or limitation of movementPain or aches in musclesFeeling of weakness or tiredness
Chest congestionAsthma, bronchitisShortness of breathDifficulty breathing
Poor memoryConfusion, poor comprehensionPoor concentrationPoor physical coordinationDifficulty in making decisionsStuttering or stammeringSlurred speechLearning disabilities
Gagging, frequent need to clear throatSore throat, hoarseness, loss of voiceSwollen or discoloured tongue, gum, lipsCanker sores
Stuffy noseSinus problemsHay feverSneezing attacksExcessive sweating
AcneHives, rashes, or dry skinHair lossFlushing or hot flushesExcessive sweating
Binge eating / drinkingCraving certain foodsExcessive weightCompulsive eatingWater retentionUnderweight
Frequent illnessFrequent or urgent urinationGenital itch or discharge
GRAND TOTAL COMMENTS:
MEDICAL INFORMATION, PERMISSION AND RELEASE FORM Health Problems we should know about:(Allergic to Bee Stings, Asthma, Diabetes, Recent Illnesses or Injuries [anything you have seen a doctor for in the past 6 months], etc.): Daily/Regular or “as needed” Medications (ex: Allergy, acne medication, etc.): A WBOP chaperone will have the following over-the-counter medications available