Preparing information

to my doctor


Before  visiting him,

a health screening check-list

Revision: 06.08.2012


Two main points:

• This memento prevents a lapse of memory.
• When printed, it will help my doctor.


Of course, I will bring the results of the examinations, personal cards, a copy of previous prescriptions as well as a list of all the other medications currently being used.

If my health has not always been perfect, the following check-list will contribute to a safer diagnosis. It is in use since more than 20 years.
It will prevent me from forgetting facts to be communicated to my doctor.
By stimulating my remembrance, I'll perhaps recall past health problems missing in the check-list.
Contra-indicated medicines would therefore not be prescribed.
Any disease detected at early stage would recover more easily .

Before any disease appears, any simple risk would be avoided.
I would even be glad to tell my doctor what I did myself for my health.

If it is a GP or a specialist or a workplace physician who cares for me, the check-list will prove equally useful.
The best time to give it to the doctor would be just before the he examines me.

If I would like to use this check-list, its text is easily copied-pasted on a single page previously formatted in three columns with 13 mm margins and Times New Roman or Arial 12 pt fonts; then printed and filled by hand.

If I hope my doctor will like it also, I may print some blank specimens for him. Would he give them to other patients when entering his waiting-room?
My workplace nurse or my hospital nurse would be glad to transmit this paper, if I like.

Around me, are there other people needing medical advice?
Would they also be glad to try the check-list and to show it to their doctors?



• If my answer is NO, I do nothing;
• If  YES, I tick after the ?
• If I am not sure, I tick
    to discuss it with the physician.

Do I take any medication?

Sleeping pills or tranquilizers?
Anticlotting drugs?

Do I have intolerance to drugs?
Any food intolerance?

Sick after an insect bite?

Had I ever undergone surgery?

Blood transfusion?

Do I sleep badly?
Does noise disturb me?

Do I get tired easily?
Anxiety, nervousness?

Recent weight loss?

Vaccinations not up to date?
Attacks of fever?

Chest pains during physical
Chest pains when at rest?


High blood pressure?

Abnormally short of breath?
Do my ankles swell?

Do I bleed too easily?

Persisting or frequent bronchitis?

Bloody spits?

Lumbago or sciatica?
Gout? Uric acid?

History of phlebitis?

Jaundice, hepatitis?

A gastric or duodenal ulcer?
Teeth: well supervised?

Parasites or intestinal worms?
Difficult digestion?

Often constipated? False needs?
Do I use laxatives?

Red or black blood in stools?
Am I on a diet?

Do I faint easily?

Was my birth difficult?
Seizure or tetany?

Memory loss?

A history of depression?
Ever had suicidal ideas?

Tremor, clumsy hands?

Nephritic colic?
Pain when passing water?

Urinating several times at night?
Albumin in urine?

Diabetes, sugar in urine?
Often very thirsty?

Bouts of dizziness?

A buzzing sensation in my ears?
Early signs of deafness?

Prolonged colds or sinusitis?

Is my voice hoarse?
Trouble swallowing?

Swollen glands?

Exposure to toxic substances?
Over ten cigarettes/day?

After-effects of an accident?

Likelihood of being HIV positive?


Bleeding between periods?
Late periods?
Excessive menstrual blood flow?
Need for contraception? Condom?

Breasts: pain? Lump?

My answers will be covered by medical confidentiality.




Age…  Height……     Weight…   kg Today's date…



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