Fuad Afzal, MD
P.O.Box 952951
Lake Mary, FL 32795
Phone: 407-896-1789 Fax: 407-896-1735
www.midfloridakidney.com

Health Questionnaire

Last Name: ______________________________ First Name: ______________________________

 

Symptoms (Please check all that apply)

 General  Gastrointestinal  Cardiovascular  Genito-Urinary  Muscle/Bone/Joint
Fever  Anorexia  Chest Pain  Painful Urination  Joint Swelling
Chills  Nausea  Palpitations  Poor Urine Stream  Muscle Weakness
Sweats  Vomiting  Rapid Heart Beat  Incontinence  Others List
Insomnia Loose Stools  Shortness of Breath  Frequent Urination  ______________
Leg Swelling  Blood in Stool  Orthopnea  Blood in Urine  ______________
Weight Loss  Constipation  Fatigue  Foamy Urine  ______________
Dizziness  Reflux      ______________

 

Health Conditions (Please check all that apply)

AIDS (HIV disease) Anemia  Arthritis  Asthma  Allergies
Bleeding Problems Bronchitis  Cancer COPD (emphysema)  Cataracts
Diabetes Epilepsy  Glaucoma  Goiter  Gout
Gall Stones Heart Disease  Hepatitis  Headaches  High BP
High Cholesterol Incontinence  Jaundice  Kidney Stones Kidney Infections
Kidney Faliure Organ Transplant Prostate Problems  Stroke  Thyroid Disease
TB List Others      

List of Medications

   
   
   
   
   
   
   
   
   

Family Medical History

 Relation  Age  State of Health

 Age at Death
 Cause of Death Check if blood relatives have the following  Relationship
 Father          Hypertension  
 Mother          Kidney Disease  
 Brothers          Heart Disease  
           Cancer  
           Arthritis  
           Gout  
           Diabetes  
 Sisters          Asthma  
             
             
             
             

Hospitalizations (including pregnancies and operations)

 Year  Hospital  Reason for Hospitalization
     
     
     
     

Allergies (Please List) _____________________________________________________________________________

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Habits (check which substances you use and indicate how much)

Tobbaco
Alcohol
Caffeine (Coffee)
Other Drugs