ANNUAL MEDICAL FITNESS QUESTIONNAIRE - AMFA

Please complete all sections accurately

Complete the following questions by ticking the relevant box. Be sure to provide all additional details in the space that follows.

PATIENT INFORMATION

Employer:

Work Location:

Assessment Date: *

Sex: *

Patient ID: *

First Name: *

Middle Name:

Last Name: *

Date of Birth: *

Phone Number: *

Email: *

LIFESTYLE QUESTIONNAIRE

Physical Wellness

Question	Never	Rarely	Sometimes	Very Often	Always
I engage in moderate exercise minimum of 3 times a week, each lasting at least 30mins
I eat balanced diet that includes fresh fruits and vegetables daily
I get enough sleep every night (at least 7 hours)
My alcohol consumption is more than 1 bottle of beer a day or more than a glass of wine/whisky a day
I abstain from tobacco use and drug abuse
I maintain a desirable weight

Mental Wellness

Question	Never	Rarely	Sometimes	Very Often	Always
I am able to recognize and manage the different stress in my life
I am flexible and adjust to life's challenges positively
I can express all ranges of feelings (hurt, sadness, fear, anger & joy)
I seek opportunities that challenge my critical thinking skills
I have a sense of purpose in my life

Social Wellness

Question	Never	Rarely	Sometimes	Very Often	Always
I give priority to my own needs by saying 'no' to 'others' when I need to
I participate in a wide variety of social activities and enjoy being with people who are different from me
I try to be a 'better person' and work on behaviours that have caused problems in my interaction with others
I balance work with playtime and other aspects of my life
I maintain a network of supportive friends and social contacts

Financial Wellness

Question	Never	Rarely	Sometimes	Very Often	Always
I create a budget and stick to it
I save a portion of my income
I have an emergency fund for unexpected expenses
I feel confident in managing my financial situation
I plan for my financial future

PAST MEDICAL HISTORY

Question	Yes	No	Comment
Have you ever had a heart attack/stroke, chest pain/heaviness, dizziness/fainting, breathlessness, palpitation?
Any history of difficulty in breathing, noisy breathing, continuous cough, or asthma?
Any history of fits, epilepsy, blackouts, migraines, recurrent headaches, concussion or head injury?
Any history of Mental Illness, Depression or Anxiety?
Any history of abdominal pain, indigestion, heartburn, yellowness of the eyes, continuous diarrhea, constipation, blood in stool, pile?
Any history of high blood sugar, thyroid disease, swelling around the neck, weight gain/weight loss, numbness in the foot/palm, excessive sweating?
Any breast discharge, breast lump, breast pain, breast swelling? (Female)
Previous history of glaucoma, ear disease or discharge?
Any history of kidney problems, difficulty urinating, painful urination, sexually transmitted infection?
Any vaginal discharge, painful coitus, vaginal bleeding? (Female)
Have you had low back pain, knee pain, arthritis, gout?
Any history of recent surgery