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| Profile of patient |
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What is included in a yearly health assessment? |
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Screening for survival needs Do you have enough of these resources from the state? Food Clothing Housing Health care Transportation Security Education Consumer goods Communication Do you need any of these resources to be enhanced? |
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Assets Clothes Communication Education Food Health care Housing Laundry |
| Stressful Life Events Screening Questionnaire (SLESQ) |
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Resident/patient or relative of patient.
____________________________________ Are you seeking annual health assessment for yourself or someone else? ____________________________________ Do you or your relative have Internet access so that you can access www.qureshiuniversity.com/healthcareworld.html? ____________________________________ If you are a relative of a resident or patient, did your relative have proper annual health assessment? ____________________________________ What is the name and profile of the person who needs annual health assessment? ____________________________________ Where is he or she now? ____________________________________ How often do you participate in at least 30 minutes of daily physical activity? ____________________________________ How often do you eat at least two cups of fruit each day? ____________________________________ How often do you eat at least 2.5 cups of vegetables each day? ____________________________________ Health assessment questions Where do you go for medical diagnosis and treatment? I utilize this location. http://www.qureshiuniversity.com/healthcareworld.html Are your medical needs being met by your current provider? Yes, they are. Almost all questions are answered at this location. http://www.qureshiuniversity.com/healthcareworld.html Do you have health insurance? Yes, I do. Take a look at recommendations I have forwarded. http://www.qureshiuniversity.com/healthinsurance.html Do you have transportation needs? I need air transportation from Chicago, Illinois, to Srinagar, Kashmir, and after one week to return to Chicago, Illinois. I need occasional ground transportation. A civilized environment needs to be ensured around me. Are you interested in learning about physical fitness? Are you interested in learning about nutrition? Are you interested in learning about healthful cooking? I do have this resource. What are you general health concerns? Do you have diabetes? No, I don’t. How often do you participate in at least 30 minutes of daily physical activity? Every day. How often do you eat at least two cups of fruit each day? Occasionally. How often do you eat at least 2.5 cups of vegetables each day? Sometimes. What are my goals? Here are the questions you need to answer. Are the health care resources you have mentioned better than those at this location:http://www.qureshiuniversity.com/healthcareworld.html? I do not have any health problem. Health care services I offer are better than others. What is their response after looking at this resourcc:http://www.qureshiuniversity.com/healthcareworld.html? I am facing intentional enforced harms. This is not a medical case. This needs legal or administrative adjudication. This is a legal or medico-legal case. A competent counselor with legal, administrative, and political expertise is required to communicate via e-mail, fax, telephone, and if required, a meeting. You and others can get insight of harms and issues at this location:http://www.qureshiuniversity.com/healthcareworld.html My remuneration/income/survival needs are not being fulfilled even though I have quality products and services. Similar products and services are getting far more remuneration. |
| Malnutrition. |
| Child abuse. |
| Personal hygiene. |
| Any complaints of misbehavior. |
| Physical fitness. |
| Hemoglobin (If normal, every five years). |
| Vision and hearing. |
| Developmental disorders. |
| Childhood obesity. |
| Immunizations. |
| Medical Record |
| Here are general preventive health care directives. |
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Primary health care includes: Annual health assessment. Diagnosis and treatment of all non-emergency medical conditions. Preventive health care advice. Patient education. Other. |
| Life Stressors |
| Medical Record |
| Patient Education |
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Postal Service
Products and Services |
| Quality of medical doctors or health care providers |
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Skills and knowledge
Security Transportation |
| Women's Health |
| Pediatric History |
| What develops? |
| Physical fitness questions |
| What happens during a physical examination? |
| Age-Appropriate Speech and Language Milestones |
| Age-Appropriate Vision Milestones |
| Age-Appropriate Hearing Milestones |
| Breast Health and Adolescents |
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What is good human character? What is good human behavior? What is fidelity? What are conjugal rights? Adolescent (13 to 18 Years) |
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Adolescent Nutrition http://www.nebraskamed.com/Health-Library/pediatric/Growth-and-Development/35237/Adolescent-13-to-18-Years |
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What kind of questions will you ask me? The health risk assessment asks general questions about your current health, such as cholesterol level, blood pressure, height and weight. It also asks questions about lifestyle choices that may affect your health, such as your exercise habits and your use of tobacco and alcohol. What if I don't know my cholesterol level or blood pressure? Don't worry! You don't need to fill in all the information to complete the health risk assessment. Of course, the more information you can provide the more accurate report of your current health age you'll receive. Will my health information remain private? Yes! Your health information will remain completely private. Learn your true health age now. What should I do if my health isn't as good as I want it to be? If you'd like to be healthier (and who wouldn't?), your personal health risk report will give you some tips that can help. But, it's also important for you to see a doctor before making major changes that could affect your health, like beginning an exercise program. If you don't have a doctor, we would be happy to help you find one. Just call 410-554-2266 or visit Find a Doctor online. Total Health Assessment Questionnaire The questionnaire below is only a sample for demonstration purposes. Any answers provided will not be processed for the generation of a personal report. Your Email Your Title First Name Lastname Your Street Number/PO Box Street Your Suburb State Postcode Work Contact Number Home Contact Number Mobile Contact Number Preferred Contact Number Best Days to be Contacted Any day OR Monday Tuesday Wednesday Thursday Friday Best Times to be Contacted Any time OR 9-12pm 12-5pm 5-8pm Complete each question as best you can, by indicating the best response. Your results will be kept strictly confidential. Be sure to click the [Continue] button at the bottom of this page, even if you wish to finish this questionnaire later. Your answers may then be held until your return up to 92 days later. 1 SECURE ID Confirmed 2 SEX Male Female 3 DATE OF BIRTH Day: Month: Year: 4 HEIGHT (without shoes) centimetres OR feet inches 5 WEIGHT (without shoes) 6 What was your latest blood pressure reading? Systolic (high number) Diastolic (low number) If you do not know the numbers, which best describes your blood pressure? Has your doctor prescribed medicine for high blood pressure? 7 What was your latest total cholesterol level? (based on a blood test) mmol/L If you do not know the number, which best describes your cholesterol? 8 What is your HDL cholesterol level? (based on a blood test) mmol/L I'm not sure HEALTH-RELATED BEHAVIOURS 9 CIGARETTE SMOKING How would you describe your cigarette smoking habits? Still smoke, Go to question 10 Used to smoke, Go to question 11 Never smoked, Go to question 12 10 STILL SMOKE cigarettes per day Go to question 12 11 USED TO SMOKE How many years has it been since you smoked cigarettes on a fairly regular basis? years What was the average number of cigarettes per day that you smoked in the 2 years before you quit? 12 Do you smoke or use pipes? cigars? smokeless tobacco? 13 How often do you use prescribed drugs or over-the-counter medication which affect your mood or help you to relax? 14 How many drinks of alcoholic beverages do you have in a typical week? (one drink = one can or stubby of regular beer, glass of wine, shot of spirits (45 ml) or can of pre-mixed spirits) drinks 15 How many times in the last month did you drive or were a passenger in a vehicle when the driver had perhaps too much to drink? times last month 16 In the next 12 months, how many kilometres will you probably drive or be a passenger in each of the following? A. Car, truck or van B. Motorcycle 17 What percent of the time do you usually buckle your seat belt when driving or a passenger? 18 On the average, how close to the speed limit do you usually drive? 19 On a typical day, how do you usually travel? 20 How many servings of fresh or frozen fruits and vegetables do you eat on a typical day? (eg 1 Serve = 1 piece of fruit, 1/2 a cup of cooked vegetables, 1 cup of raw vegetables) 21 How often do you eat fast food? 22 In the average week, how many times do you engage in moderate-intensity physical activity for at least 30 minutes? Examples include things such as a brisk walk or cycling. QUALITY-OF-LIFE INDICATORS 23 In general, how satisfied are you with your life? (include personal and professional aspects) 24 Would you agree you are satisfied with your job? 25 In general, how strong are your social ties with your family and/or friends? 26 Considering your age, how would you describe your overall physical health? 27 How many hours of sleep do you usually get at night? 28 Have you suffered a personal loss or misfortune in the past year? (for example: a job loss, disability, separation, gaol term, or the death of someone close to you) 29 How often do you feel tense, anxious, or depressed? 30 During the past year, how much effect has stress had on your health? 31 In the past year, how many days of personal illness have you had that kept you from your normal activities? MEDICAL HISTORY AND SELF-CARE 32 Do you have a family history (brother, sister, mother, father, grandparents) of: High blood pressure Heart problems Diabetes Cancer High cholesterol 33 Have you had: Heart problems Diabetes Cancer Chronic bronchitis/emphysema Past stroke Asthma Arthritis Allergies Back pain 34 When was the last time you had these preventive services or health screenings? Faecal occult blood test Flu shot Tetanus shot Blood pressure check Cholesterol check Check for skin cancer by a doctor or nurse for Women Only Pap test Mammogram Breast exam by a doctor or nurse for Men Only Digital rectal exam for your prostate 35 In the past 12 months, how many times have you: Visited a doctor's office or clinic as a patient Gone to the hospital emergency department (Casualty) for treatment Stayed overnight in a hospital as a patient Used a toll-free number for medical advice Used a self-care book Been treated with alternative medicine Women (Men go to question 37) 36 How many women in your natural family (mother and sisters only) have had breast cancer? PERSONAL INFORMATION 37 Relationhip 38 In which _________ were you born? 39 Are you __________ origin? 40 What is the highest level of education you have completed? HEALTH PLANNING QUESTIONS 41 Have you made any of these changes to enhance your health during the past 12 months? Increased physical activity Lost weight Reduced alcohol use Quit or cut down smoking Reduced fat/cholesterol intake Lowered blood pressure Lowered cholesterol level Coped better with stress 42 Are you planning to make any changes to keep yourself healthy or improve your health in the next 6 months? Increase physical activity Lose weight Reduce alcohol use Quit or cut down smoking Reduce fat/cholesterol intake Lower blood pressure Lower cholesterol level Cope better with stress |