MEDICAL QUESTIONNAIRE
PTET-NEPAL COMMITTEE  of   Kathmandu, Nepal

NAME   : ___________________________________________________________                  DATE :____/____2002

HOMETOWN _______________________________________________________ , Nepal

PRISON :  ___________________________________                                            BUILDING NUMBER ____________
AGE       : ___________________
DATE ARRESTED __________________________                       DATE of EXPECTED RELEASE :_______________

PRE-EXISTING MEDICAL CONDITIONS :    (   your medical history before coming to prison  )
  Did you have(circle)  : diabetes, blood or heart problems, high blood pressure, TB, typhoid , athsma: other________________
  Were you a smoker    : Y/N .  If Yes: then when started _____    how long smoking ______ how many cigarettes per day ____
  Any allergic reaction to : food, medication, vaccinations :  Which ? : ______________________________________________
           What kinds of reaction ?___________________________________________  Other :  ___________________________
CURRENT MEDICAL CONDITIONS: ( nowadays ):
General Health (circle) : Great, OK, Poor, Terrible :  Explain : _________________________________________

HEAD: Do you have headaches(circle)  ( never, sometimes, often) :  If so then when(day,night): explain _____________
     Are your hands normally (warm,cold ...  tension often makes blood flow away from hands leading to poor digestion) :
                            explain : ______________
EYES (circle choice) : OK, getting better, getting worse :  explain: ____________________________________________
     Any of these :  blurry vision,  "spots",  "watering eyes", "mucous" in morning or  night________: How long ________
     Maximum distance you can read this questionnaire (circle) : 3 meters, 1 meter, half meter, 10 cm.

EARS: (circle choice) : OK, getting better, getting worse :  explain: ___________________________________________
     Any of these : deafness , buzzing, ringing , other : ( which ear ) ___    How long ? _____________________________

NOSE and BREATHING ... ( and TB questions )
     Any problem with coughing ( yes/no):  If YES then , do you cough up pus  ( yes/no)?  : Explain ___________________
     What Color (green is worst ) ________  How long ? _________ How many hours ________ : Day or night ? ________
     TB: did you ever have it (yes/no ) .. When ___ How long treatment ?_____\
     Have you had any sudden weight loss, tiredness or other TB symptoms (yes/no) : When and how much? ___________ 

MOUTH / THROAT / STOMACH
    Any sores inside your mouth?? Where___________________________________________________ How long ? _________
    Teeth: OK, many rotting, few rotting, holes : Which ones/how many ? :____________________________________________ 
    GUMS (soft part near teeth) : OK / bad / painful or bleeding : explain  :____________________________________________
    Do you have ulcers ? ( how did you diagnose ? ) : ______________________________________________________________
CARDIO-VASCULAR:
   How much do you weigh ? ______( Kg ).     What is height______(meters) :   Are you fat or skinny : explain: ______________
   Do you run or have heavy exercise every week (circle) : YES / NO : 
          What exercise _________________________ _______________________________  How many hours per week ______
   Exercise Heart rate : ___________ ( measure heart-beats for only 6 seconds ):
   How do you feel ? (circle) : GREAT,  OK , Good, Terrible :    If dizzy : how long ____________________________
   Do you do any YOGA or MEDITATION exercises (yes/no) : How long per week :  ___________________________

DIGESTION, STOMACH:
   Stomach (circle?) OK, some pains , burning (acid indigestion) , aches :  Where ______ When(day/night) ?_________
             Are you allergic to peppers, spices .. other ____________________________________________________________
             How many hours/day is this problem ?  _____________   When did it start? _________________________________


PEE and SHIT:
   Pee ( urination, #1, tato pani .. etc ): Any problems (never, sometimes, always) : How long ? _________ _______________
       Is the  pain (circle) before, during or after urination : explain : ______________________________________________
       Is there blood or "puss/mucous" coming out ? : Whay/ How much ________________________ How long ___________
   Stools,  Shit or #2  : Any problems with pain, hemorrhoids, blood (  red or black color ) : how often? __________________
       If hemorrhoids then : Are you allergic to peppers or other foods, doing too much exercise or what ?__________________ 
_______