Medical History Questionnaire. Each Club shall utilize the Medical History Questionnaire developed by the Club physicians in connection with the Club’s initial physical examination of the Player. The current Medical History Questionnaire is attached hereto as Attachment 6.
Medical History Questionnaire i) To be completed by the inmate, with the assistance of a dental staff member as needed.
ii) It is important that the dental staff insure the inmate has properly reviewed and understand the medical history questions. If necessary the questions can be read to the Inmate.
iii) The dental staff reviewing the Medical History questionnaire should circle in red the questions marked YES, as well as circle the particular condition (if applicable).
(1) It is recommended that the inmate’s blood pressure and pulse be taken. The personnel taking the readings will initial the recordings.
c) Section 3: After completion of section 1 and 2.
i) Ensure the Inmate reads and understands the segment (or read it to them) concerning risk concerning treatment, correctness of the answered medical questionnaire, ability to ask questions, and consent for treatment. Have the inmate place their initials after this segment.
ii) Then the Inmate must sign and date this page. The dentist should immediately sign and date the Medical History page after reviewing the medical history data.
Medical History Questionnaire. To be completed by the inmate, with the assistance of a dental staff member as needed.
Medical History Questionnaire. Thank you for taking the time to fill out this questionnaire. The more information we have about you, the better we can work together to help you. In your own words, please write the nature of the medical problem for which you are being seen for today. I leak urine. If true, for how long? I have to wear pads because of losing urine. If so, how many do you use each day? My bladder problem is bad enough that I would request surgery to fix it. I have had an operation on my bladder. If true, how was the operation was performed? Abdominally Vaginally The operation I had on my bladder cured my problem. The operation I had on my bladder helped my problem for a time. If true, how long did the operation help? The operation I had on my bladder did not help at all. I leak urine when I cough, sneeze, exercise or move suddenly. I lose urine in small spurts. I lose large amounts of urine and once the leakage begins I cannot control it. If I cough hard, I leak at the same time. If I cough hard, the leaking comes a few seconds later. I have trouble starting my urine stream. My urine stream is no more than a dribble. It takes me a long time to empty my bladder. After I urinate, I often feel I have not completely emptied. I leak urine with sexual intercourse. I often feel the urge and need to urinate even when my bladder is not very full. The sound, sight, or feel of running water gives me the urge to urinate. The sound, sight, or feel of running water actually causes leakage of urine. If I suddenly stand up after sitting or lying down, I lose urine. I am not aware that I am losing urine until I notice I am wet. I urinate more than eight times a day. The need to urinate routinely wakes me up at least two times during the night. There is blood in my urine. I have had two or more bladder infections in the last year. Intercourse causes me to have bladder infections. I have pain in the area of my bladder. It hurts to urinate. I have been treated by urethral dilatation. I had trouble wetting the bed as a child. I have trouble wetting the bed now. My urine loss is a continual drip, I am always wet. A Medical Corporation Never Less than 2 times/month 2 or more times/month Never Less than 2 times/month 2 or more times/month Never Less than 2 times/month 2 or more times/month Never Up to 25% of the time Up to 50% of the time Up to 75% of the time Up to 100% of the time Never Up to 25% of the time Up to 50% of the time Up to 75% of the time Up to 100% of the time Never Up to 25% of t...
