Microsoft word - questionnaire small patients follow-up english.doc

Could you please fill in this questionnaire and bring it at the next appointment ? Your answers will enable us to help you better. DATE :…………………………………
NAME : …………………………………………………………………………………………………………
How are you doing ?

Improvements since last consultation ? ………………………………………………….
…………………………………………………………………………………………………………………
…………………………………………………………………………………
Complaints ?
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………
Since last consultation :

Did you undergo :

Your present treatment (of the last weeks) ? :
MEDICATION
DAILY DOSAGE
Hormones :
…………………………………….… 1. Thyroid ?
………………………………….…… 2. Female ?
……………………………….……… …………………………….………… ………………………….…………… ……………………….……………… 4. Hydrocortisone (or derivates) ?
……………………….……………… …………….……… 5. Other ?
…………………….………………… Vitamins/minerals/trace elements:
- …………………………………… ………………………………. - …………………………………… ………………………………. - …………………………………… ………………………………. - …………………………………… ………………………………. Other treatments ?
………………………………….…… …………………………….………… ……………………….……………… How is your present medical condition ?

Please fill in the cases which closely correspond to your present medical condition (fill in one case per
symptom)
(If you are out of time, fill in at least the questions marked in bold).
No Few Moderately A lot Very much
Never Sometimes Regularly Often Always
Thyroid hormones :
Excessive sensitivity to cold ?
Fatigue in the morning ?
Depressed ?
Headaches ?
Swollen eyelids (especially in the morning) ? Muscle cramps in feet/calves at night ?
Stiff joints when getting up in the morning ?
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1.
Tachycardia (quick heart beats) ?
Cortisol
Poor resistance to stress ?
Low blood pressure ?
Sugar or sweet cravings ?
Joint pain in the :

- Upper body, where? ……………………….
- Lower body, where ? ……………………….
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1.
Swollen face (like a balloon) ?
III. DHEA

1.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
IV. Aldosterone

1.
Feeling better when laying down on bed ?
Need to quickly urinate after drinking ? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
V. Sexual
hormones
Permanent fatigue (the whole day) ?
Hot flushes ?
Heart pain during exercise or after stress ? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -VI.
Male
hormones
Decreased muscular strength ?
For adults : - decreased libido (sexual desire) ? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1. Excessive agressivity / dominant character ? Oily skin ?
Greasy hair ?
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
VII. Oestrogens
1.
- droopy breasts ?
- dry vagina ?
- irregular periods ?
(27-31j.) (26 j. or less) (32 j. or more) VIII. Progesterone
- Heavy blood loss ?
- Painful, swollen breast before the periods ?
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
IX. Melatonine

1.
Light, anxious, agitated sleep ?
but getting up to early, and having a heavy ________________________________________________________________________________________
Growth hormone
Sagging cheeks ?
Aging body ?
Droopy inner side of legs
Cellulite
10. Low quality of life ?
Excessive emotional sensitivity ?
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1.
NUTRITION :
What do you eat ?
In the morning Make a circle around the food you eat regularly
Fruit

Others :
At 11 a.m.:

At 4 p.m.:

At lunch or dinner :
Salad

Source: http://www.agenda-hertoghe.eu/fu/SMALL_QUESTIONNAIRE_FOLLOW-UP_v1_EN.pdf