Health Questionnaire

Welcome to the MYMOP (Measure My Medical Outcome Profile). The MYMOP is a way to gauge your subjective results over time. We aim to measure the outcomes that YOU, the patient considers the most important. We start our initial appointment with this and we can track your subjective measures as we go along. You can fill this form out at any time from home in order to keep your practitioner updated. Simply click on your practitioners name and the email will get sent directly to their email address. You can discuss these results in your follow up appointments. You can also feel free to fill out the MYMOP even after you have finished working together.

MYMOP

Measure My Medical Outcome Profile

Full name*
Today's Date*
DD slash MM slash YYYY
Your practitioner*
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simone@the-apothecary.co.nz
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sarka@the-apothecary.co.nz
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melody@the-apothecary.co.nz
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heather@the-apothecary.co.nz
Email*
Please enter your email address
Enter Email Confirm Email
Symptom 1*
Choose the symptom then pick a number to show how severe your problem has been IN THE LAST WEEK - 0 being as good as it could be and 6 being as bad as it could be
Please name your symptom
Symptom 1 score
Choose the number to show how severe your problem has been IN THE LAST WEEK - 0 being as good as it could be and 6 being as bad as it could be
Symptom 2*
Choose the symptom then pick a number to show how severe your problem has been IN THE LAST WEEK - 0 being as good as it could be and 6 being as bad as it could be
Please name your symptom
Symptom 2 score*
Choose the number to show how severe your problem has been IN THE LAST WEEK - 0 being as good as it could be and 6 being as bad as it could be
Activity
Choose one activity - physical, social or mental - that is important to you, and that your problem makes difficult or prevents you doing. Score how bad it has been in the last week.
Please name your activity
Activity score*
Score how bad it has been IN THE LAST WEEK - 0 being as good as it could be and 6 being as bad as it could be
Wellbeing*
How would you rate your general feeling of wellbeing over the last week
Lifestyle changes
The treatment you are receiving may not be the only thing affecting your problem. If there is anything else that you think is important, such as lifestyle changes you have made yourself, or other things happening in your life, please write it here
Medication*
Are you taking any medication FOR THIS PROBLEM
Please write in the name of your medication(s) for this problem
Is cutting down this medication*

Please feel free to fill these out when significant changes occur, even after you have finished working together.

Health Questionnaire

MYMOP

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