UMHLANGA OCCUPATIONAL HEALTH

 DR DG GOVENDER

Unit 14, The Zen

31 Zenith Drive

Umhlanga Ridge

​Tel: 031 566 2066

Cell: 083 661 4332

Email: admin@drdg.co.za

EXECUTIVE MEDICAL QUESTIONAIRE

PERSONAL DETAILS

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SOCIAL HISTORY

FAMILY HISTORY

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MEDICAL HISTORY

2.Cadiovascular
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3. GIT
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4. Respiratory
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5. Neurological
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6. Musculo Skeletal
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7. Endocrinological
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8. Skin Disorders
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9. Psychological
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10. Males - Prostate disorders
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11. Females - Gynaecological problems
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Breast Lumps
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VACCINATION HISTORY

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OTHER

Screening Tests
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Travel illness
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CURRENT MEDICATION

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We deeply appreciate you taking the time to fill out this medical questionnaire. Thank you for your cooperation.

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Yours In Wellness

Thank You

DR DG GOVENDER

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