Long Term Care Questionnaire

First Name *

Middle Name

Last Name *

Gender

Male

Female

Other

Phone Number

Email *

Date of Birth

Height

Weight (lbs)

State of Residence

Are You a U.S. Citizen / Permanent Resident / Green Card Holder?

Yes

No

PLEASE NOTE YOUR CURRENT RESIDENCY STATUS IN THE U.S. AND INDICATE WHAT VISA YOU CURRENTLY HOLD:

Country of Citizenship

Visa

Are You Applying With Your Spouse

Yes

No

Please complete a separate form for your spouse

Do You UseTabacco Or Tabacco Products?

Yes

No

Date you last smoked?

On average, how many per day

Date you last smoked?

On average, how many per day

Date you last smoked?

On average, how many per day

Date you last smoked?

On average, how many per day

Date you last used?

On average, how many per day

Date you last used?

On average, how many per day

Are You Currently Receiving Physical Therapy

Yes

No

Do You Use A Cane, Walker Wheelchair, etc?

Yes

No

Have You Ever Been Confined To A Nursing/Rehabilitation Facility?

Yes

No

When Did You Last See A Doctor

For What reason/Condition Did You Last See The Doctor

DO YOU HAVE SYMPTOMS OF OR WITHING THE LAST 10 YEARS HAVE YOU RECEIVED MEDICAL ADVICE, DIAGNOSIS OR TREATMENT OR CONSULTED WITH A MEMBER OF THE MEDICAL PROFESSION FOR ANY OF THE FOLLOWING CONDITIONS?

Heart Disease

No

Yes

Congenital Heart Disease

Date of Onset/Diagnosis

Arrhythmia

Date of Onset/Diagnosis

Coronary Artery Disease

Date of Onset/Diagnosis

Dilated Cardiomyopathy

Date of Onset/Diagnosis

Myocardial Infarction

Date of Onset/Diagnosis

Hypertrophic Cardiomyopathy

Date of Onset/Diagnosis

Mitral Regurgitation

Date of Onset/Diagnosis

Mitral Valve Prolapse

Date of Onset/Diagnosis

Pulmonary Stenosis

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Coronary Artery Disease

No

Yes

Obstructive Coronary Artery Disease

Date of Onset/Diagnosis

Non-Obstructive Coronary Artery Disease

Date of Onset/Diagnosis

Spontaneous Coronary Artery Dissection

Date of Onset/Diagnosis

Obstructive Coronary Artery Disease

Date of Onset/Diagnosis

List:

Circulatory Disorders

No

Yes

Atherosclerosis

Date of Onset/Diagnosis

Myocardial Infarction

Date of Onset/Diagnosis

Mitral Prolapse, Stenosis, Regurgitation

Date of Onset/Diagnosis

Angina Pectoris

Date of Onset/Diagnosis

Arrhythmia/Dysrhythmia

Date of Onset/Diagnosis

Ischemia

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Hypertension

No

Yes

Isolated Systolic Hypertension

Date of Onset/Diagnosis

Malignant Hypertension

Date of Onset/Diagnosis

Residental Hypertension

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

High Blood Pressure

No

Yes

Systolic

Diastolic

Leukemia

No

Yes

Acute Myeloid (or Myelogenous) Leukemija (AML)

Date of Onset/Diagnosis

Chronic Myeloid (or Myelogenous) Leukemia (CML)

Date of Onset/Diagnosis

Acute Lymphocytic (or Lymphoblastic) Leukemia (ALL)

Date of Onset/Diagnosis

Chronic Lymphocytic Leukemia (CLL)

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Lymphoma

No

Yes

B-cell Lymphoma

Date of Onset/Diagnosis

T-cell Lymphoma

Date of Onset/Diagnosis

Burkitt's Limphoma

Date of Onset/Diagnosis

Follicular Lymphoma

Date of Onset/Diagnosis

Mantle Cell Lymphoma

Date of Onset/Diagnosis

Primary Madiastinal B-cell Limphoma

Date of Onset/Diagnosis

Small Limphocytic Limphoma

Date of Onset/Diagnosis

Waldenstrom Macroglobulinemia (Lymphoplastmacytic Limphoma)

Date of Onset/Diagnosis

Limphocyte-depleted Hodgkin's Disease

Date of Onset/Diagnosis

Limphocyte-rich Hodgkin's Disease

Date of Onset/Diagnosis

Mixed Cellularity Hodgkin's Lymphoma

Date of Onset/Diagnosis

Nodular Lymphocyte-predominant Hodgkins Disease

Date of Onset/Diagnosis

Nodular Sclerosis Hodgkin's Limphoma

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Cancer

No

Yes

Bladder Cancer

Date of Onset/Diagnosis

Bone Cancer

Date of Onset/Diagnosis

Bowel Cancer

Date of Onset/Diagnosis

Brain Cancer

Date of Onset/Diagnosis

Breast Cancer

Date of Onset/Diagnosis

Childhood Cancer

Date of Onset/Diagnosis

Cervical Cancer

Date of Onset/Diagnosis

Gastrointestinal Cancer

Date of Onset/Diagnosis

Gynaecological (Women's) Cancer

Date of Onset/Diagnosis

Head And Neck Cancer

Date of Onset/Diagnosis

Kidney Cancer

Date of Onset/Diagnosis

Liver Cancer

Date of Onset/Diagnosis

Lung Cancer

Date of Onset/Diagnosis

Laryngeal Cancer

Date of Onset/Diagnosis

Mesothelioma

Date of Onset/Diagnosis

Mouth Cancer

Date of Onset/Diagnosis

Myeloma

Date of Onset/Diagnosis

Nasopharyngeal Cancer

Date of Onset/Diagnosis

Oesophageal Cancer

Date of Onset/Diagnosis

Ovarian Cancer

Date of Onset/Diagnosis

Pancreatic Cancer

Date of Onset/Diagnosis

Paranasal Sinus And Nasal Cavity Cancer

Date of Onset/Diagnosis

Prostate Cancer

Date of Onset/Diagnosis

Skin Cancer

Date of Onset/Diagnosis

Stomach (Gastric) Cancer

Date of Onset/Diagnosis

Uterine Cancer

Date of Onset/Diagnosis

Vaginal Cancer

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Paralysis

No

Yes

Monoplegia

Date of Onset/Diagnosis

Hemiplegia

Date of Onset/Diagnosis

Paraplegia

Date of Onset/Diagnosis

Triplegia

Date of Onset/Diagnosis

Quadriplegia

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Stroke

No

Yes

Transient Ischemia Stroke

Date of Onset/Diagnosis

Ischemia Stroke

Date of Onset/Diagnosis

Hemorrhagic Stroke

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Bowel Disorders

No

Yes

Gastroesophageal Reflux Disease (GERD)

Date of Onset/Diagnosis

Gallstones

Date of Onset/Diagnosis

Celiac Disease

Date of Onset/Diagnosis

Crohn's Disease

Date of Onset/Diagnosis

Ulcerative Colitis

Date of Onset/Diagnosis

Irritable Bowel Syndrome

Date of Onset/Diagnosis

Hemorrhoids

Date of Onset/Diagnosis

Diverticulitis

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Bladder Disorders

No

Yes

Cystitic

Date of Onset/Diagnosis

Urinary Incontinence

Date of Onset/Diagnosis

Overactive Bladder

Date of Onset/Diagnosis

Interstitial Cystitis

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Prostate Disorders

No

Yes

Benign Prostatic Hyperplasia

Date of Onset/Diagnosis

Prostatitis

Date of Onset/Diagnosis

Prostate Cancer

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Liver Disorders

No

Yes

Hepatitis A

Date of Onset/Diagnosis

Hepatitis B

Date of Onset/Diagnosis

Hepatitis C

Date of Onset/Diagnosis

Autoimmune Hepatitis

Date of Onset/Diagnosis

Primary Sclerosing Cholangitis

Date of Onset/Diagnosis

Liver Cancer

Date of Onset/Diagnosis

Bile Duct Cancer

Date of Onset/Diagnosis

Liver Cell Adenoma

Date of Onset/Diagnosis

Hemochromatosis

Date of Onset/Diagnosis

Hyperoxaluria

Date of Onset/Diagnosis

Wilsons Disease

Date of Onset/Diagnosis

Alpha-1 Antitrypsin Deficiency

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Diabetes

No

Yes

Type 1 Diabetes

Date of Onset/Diagnosis

Type 2 Diabetes

Date of Onset/Diagnosis

Gastational Diabetes (GDM)

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Depression

No

Yes

Major Depression (Clinical Depression)

Date of Onset/Diagnosis

Dysthymia (Persistent Depressive Disorder)

Date of Onset/Diagnosis

Manic Depression (Bipolar Disorder)

Date of Onset/Diagnosis

Postpartum Depression (Peripartum Depression)

Date of Onset/Diagnosis

Seasonal Affective Disorder (SAD)

Date of Onset/Diagnosis

Psychotic Depression

Date of Onset/Diagnosis

Premenstrual Dysphoric Disorder (PMDD)

Date of Onset/Diagnosis

Atypical Depression Situational Depression (Reactive Depression/Adjustment Disorder)

Date of Onset/Diagnosis

Situational Depression (Reactive Depression/Adjustment Disorder)

Date of Onset/Diagnosis

Disruptive Mood Dysregulation Disorder (DMDD)

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Alcoholism

No

Yes

Young Adult Subtype

Date of Onset/Diagnosis

Functional Subtype

Date of Onset/Diagnosis

Intermediate Familial Subtype

Date of Onset/Diagnosis

Young Antisocial Subtype

Date of Onset/Diagnosis

Chronic Severe Subtype

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Drug Addiction

No

Yes

Prescription Madication (Painkillers, Stimulants, Anti-anxiety pills)

Date of Onset/Diagnosis

Methamphetamines

Date of Onset/Diagnosis

Cocaine

Date of Onset/Diagnosis

Opiates

Date of Onset/Diagnosis

Marijuana

Date of Onset/Diagnosis

Hallucinogens

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Kidney Disorders

No

Yes

Chronic Kidney Disease

Date of Onset/Diagnosis

Kidney Stones

Date of Onset/Diagnosis

Glomerulonephritis

Date of Onset/Diagnosis

Polycystic Kidney Disease

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Osteoporosis

No

Yes

Primary Osteoporosis

Date of Onset/Diagnosis

Secondary Osteoporosis

Date of Onset/Diagnosis

Osteogenesis Imperfecta

Date of Onset/Diagnosis

Idiopathic Juvenile Osteoporosis

Date of Onset/Diagnosis

Postmenopausal Osteoporosis

Date of Onset/Diagnosis

Senile Osteoporosis

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Arthritis

No

Yes

Osteoarthritis

Date of Onset/Diagnosis

Rheumatoid Arthritis

Date of Onset/Diagnosis

Psoriatic Arthritis

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Reproductive Organ Disorders

No

Yes

Endometriosis

Date of Onset/Diagnosis

Uterine Fibrosis

Date of Onset/Diagnosis

Gynecological Cancer

Date of Onset/Diagnosis

HIV/AIDS

Date of Onset/Diagnosis

Polycystic Ovary Syndrome (PCOS)

Date of Onset/Diagnosis

Testicular Cancer

Date of Onset/Diagnosis

Enlarged Prostate Or BPH

Date of Onset/Diagnosis

Erectile Dysfunction

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Respiratory Disorders

No

Yes

Asthma

Date of Onset/Diagnosis

Chronic Obstructive Pulmonary Disease (COPD)

Date of Onset/Diagnosis

Chronic Bronchitis

Date of Onset/Diagnosis

Emphysema

Date of Onset/Diagnosis

Lung Cancer

Date of Onset/Diagnosis

Cystic Fibrosis/Bronchiectasis

Date of Onset/Diagnosis

Pneumonia

Date of Onset/Diagnosis

Pleural Effusion

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Shortness of Breath

No

Yes

Hyperventilation

Date of Onset/Diagnosis

Dyspnea

Date of Onset/Diagnosis

Bradypnea

Date of Onset/Diagnosis

Tachypnea

Date of Onset/Diagnosis

Hyperpnea

Date of Onset/Diagnosis

Kussmaul Breathing

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Fainting Spells

No

Yes

Vasovagal Syncope

Date of Onset/Diagnosis

Carotid Sinus Syncope

Date of Onset/Diagnosis

Situational Syncope

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Dizziness

No

Yes

Presyncope

Date of Onset/Diagnosis

Disequilibrium

Date of Onset/Diagnosis

vertigo

Date of Onset/Diagnosis

Non Specific Dizziness

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Seizures

No

Yes

Absence Seizures

Date of Onset/Diagnosis

Tonic-Clonic or Convulsive Seizures

Date of Onset/Diagnosis

Atonic Seizures

Date of Onset/Diagnosis

Clonic Seizures

Date of Onset/Diagnosis

Tonic Seizures

Date of Onset/Diagnosis

Myoclonic Seizures

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Tremors

No

Yes

Resting Tremors

Date of Onset/Diagnosis

Action Tremor

Date of Onset/Diagnosis

Essential Tremor

Date of Onset/Diagnosis

Dystonic Tremor

Date of Onset/Diagnosis

Cerebellar Tremor

Date of Onset/Diagnosis

Psychogenic Tremor

Date of Onset/Diagnosis

Other

Date of Onset/Diagnosis

List:

Elevated Cholesterol

No

Yes

HDL

LDL

Total

PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING

NAME OF MEDICATION/ DATE STARTED/ CONDITION/REASON AND & DATE OF DIAGNOSIS/ DOSAGE/ FREQUENCY

Medication 1

Medication Name *

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

Medication 2

Medication Name *

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

Medication 3

Medication Name *

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

Medication 4

Medication Name

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

Medication 5

Medication Name *

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

Medication 6

Medication Name *

Condition/Reason *

Date of Diagnosis *

Dosage (mg) *

Frequency *

PLEASE LIST ANY OTHER DIAGNOSED/KNOWN HEALTH ISSUES OR RELEVANT HEALTH INFORMATION

1.

2.

3.

PLEASE LIST DETAILS OF ANY SURGERIES YOU HAVE UNDERGONE AND DATE(S)

Surgery

Date of Surgery

Surgery

Date of Surgery

Surgery

Date of Surgery

Surgery

Date of Surgery

Who were you referred by?

Relationship to you

Other relatioship

Date

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