Medical Assessment Form
PERSONAL INFORMATION
Full Name
*
Gender
*
Please Select
Male
Female
Not willing to Disclose
Date of Birth
*
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Day
Please select a month
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Month
Please select a year
2025
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Year
Address
*
Street Address
City
Have you been vaccinated for Covid-19?
*
Yes
No
What vaccine?
Pfizer- BioNTech
Oxford- AztraZeneca
CoronaVac- SinoVac
Johnson and Johnson's- Janssen'
Gamelaya- Sputnik
Moderna
When did you get your 1st shot?
Date
. Your 2nd shot?
Date
Have you had any direct contact with a confirmed case of Covid-19?
Yes
No
If Yes, how many times have you been exposed to Covid-19 Positive cases?
Other
Where did you get your exposure to Covid-19 from?
Family Member
Relative
Workmates
Friends
Have you been tested positive for Covid-19?
Back
Next
PERSONAL MEDICAL HISTORY
ALLERGY:
Foods, medications or dust
ALLERGIC REACTION:
DISEASE/CONDITION:
Current
Past
Date Diagnosed, Experienced Symptoms, Treatment
Asthma
1
2
Cancer (Type)
3
4
Diabetes (Type)
5
6
High Blood Pressure (Hypertension)
7
8
Heart Disease
9
10
Renal/Kidney Disease
11
12
Migraine Headaches
13
14
High Cholesterol
15
16
Other:
17
18
Other Minor Health Complaints (e.g Headache, Back Pain)
SURGERIES:
Type(Specify Left or Right)
Date of Surgery
Location/Facility
1
2
3
MEDICATIONS:
Medications
Dose(how many milligram)
Times Per Day
1
2
3
MENTAL HEALTH
In the past 4 weeks,
None of the time
A little of the time
Some of the time
Most of the time
All of the time
1. How often did you feel tired for no good reason?
19
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22
23
2. How often did you feel nervous?
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28
3. How often did you feel so nervous that nothing can calm you down?
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33
4. How often did you feel hopeless?
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38
5. How often did you feel restless?
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43
6. How often did you feel so restless that you could not sit still?
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7. How often did you feel depressed?
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8. How often did you feel that everything was an effort?
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9. How often did you feel so sad that nothing could cheer you up?
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10. How often did you feel that you're worthless?
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