New Life Advance International

1

New Life Advance International

PO Box 35857

Houston, TX 77235-5857

Tel: 832.242.7750

HEALTH QUESTIONAIRE

Note: All responses are confidential. If deemed appropriate, and only upon receipt of your written authorization, your health information will be referred to licensed physicians and/or mental health professionals for further evaluation. Once completed, please email and mail to addresses above.

Name: ______

LastFirstMiddle

Date: ______Marital Status: S M W DSex: ______Age: ______

Present Address: ______

Street City State Zip

Birth Place: ______DOB: ______Date of Marriage: ______

When contemplating appointment? ______Country of Service: ______

City: ______Type of Ministry: ______

Have you served previously with NLAI? ______When? ______Where? ______

FAMILY HISTORY

Hereditary of Family Diseases

Mark X after any that pertains to your immediate family: father, mother, grandparents, uncles or first cousins. Give further details below.

1. Cancer ______6. Obesity______Recurring headaches: ______

2. Goiter ______7. Kidney disease ____ 12. Convulsions ______

3. Athsma ______8. Tuberculosis ______13. Heart/circulatory disease ___

4. Allergies _____ 9. Nervous Breakdown ______

5. Diabetes _____ 10. Mental disorders ______

______

______

______

______

______

INFECTIOUS DISEASES: Give year of illness if possible.

1. Chicken Pox ______7. Influenza ______13. Rheumatic Fever ______

2. Measles ______8. Pleurisy ______14. Typhoid Fever ______

3. German Measles ______9. Dysentery ______15. Tuberculosis ______

4. Mumps ______10. Pneumonia ______16. Poliomyelitis ______

5. Scarlet Fever ______11. Malaria ______17. Hepatitis ______Type ____

6. Tonsillitis ______12 Diptheria _____18. Other ______

OTHER ILLNESSES

______

______

______

______

GENERAL HEALTH INFORMATION (For Yes answer, give details e.g. dates, seriousness, etc.)

HEALTH HABITS

REVIEW OF SYSTEMS

EYES:

EARS:

NOSE, SINUSES AND THROAT:

GUMS AND TEETH:

RESPIRATORY SYSTEM:

CARDIO-VASCULAR SYSTEM:

URINARY SYSTEM:

BONES AND JOINTS:

MUSCLES:

SKIN:

METABOLISM:

DIGESTIVE SYSTEM:

NERVOUS SYSTEM:

EMOTIONAL SYSTEM:

MISCELLANEOUS:

PREVIOUS EXAMS:

Have you had X-rays of the following:

GENERAL HEALTH DATA:

Estimate of present health (circle one): Vigorous Good Fair Poor

Height: ______Weight: ______

Maximum weight: ______When (yr): ______

Recent weight changes: Plus ______Minus: ______

Recent blood pressure (if known): ______

Blood Type: ______Rh: ______

Scars or other marks on body: ______

Time loss from school or work in the past 5 years due to illness: ______

How many cups of coffee do you drink per day? ______

How many hours do you sleep a night (average)? ______

Do you take regular exercise? ______

What hobbies do you have? ______

WOMEN ONLY:

Age onset of menstruation: ______

Interval between periods: ______

Duration of periods: ______

Quantity of flow (No. pads per day): ______

Number of pregnancies: ______

Number of miscarriages, stillbirths or abortions (give dates): ______

Number of normal deliveries (give dates): ______

If pregnant, give expected date of delivery: ______

Signature of Applicant: ______Date: ______

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(Do not write below this line)

Recommendation by Medical Consultant: