kameronhealth.com Health History

Health History
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Marital Status
Previous Referring Doctor
Date of last physical exam

MonthDayYear
Date
Personal Health History
Childhood Illness
Immunizations and dates:
Tetanus

MonthDayYear
Date
Hepatitis

MonthDayYear
Date
Influenza

MonthDayYear
Date
Pneumonia

MonthDayYear
Date
Chickenpox

MonthDayYear
Date
MMR (Measles, Mumps, Rubella)

MonthDayYear
Date
List any medical problems that other doctors have diagnosed
List any surgeries, date(s), reason(s), and the hospital(s) they were performed in
List any other hospitalizations
Have you ever had a blood transfusion?
List your prescribed drugs and over-counter drugs, such as vitamins and inhalers
Any allergies to medications?
HEALTH HABITS AND PERSONAL SAFETY
All questions in this section are optional and will be kept strictly confidential
Exercise
Are you dieting?
If you are dieting, are you on a physician prescribed medical diet?
Number of meals you eat in an average day?
Rank salt intake
Rank fat intake
Caffeine?
Numer of cups/cans per day?
Do you drink alcohol?
If yes, what kind?
How many drinks per week?
Are you concerned about the amount you drink?
Have you considered stopping?
Have you ever experienced blackouts?
Are you prone to binge drinking?
Do you drive after drinking?
Do you use tobacco?
How many cigarettes per day?
How much chew per day?
How many pipe fulls per day?
How many cigars per day?
How many years have you been using tobacco? Or what is the year that you quit?
Do you use recreational or street drugs?
Have you ever given yourself street drugs with a needle?
Are you sexually active?
If yes, are you trying for pregnancy?
If not trying for pregnancy, what kind of contraceptive or barrier method do you use?
Any discomfort with intercourse?
Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse.
Would you like to speak with your provider about your risk of this illness?
Do you live alone?
Do you have frequent falls?
Do you have vision or hearing loss?
Do you have an Advance Directive and/or Living Will?
Would you like information on the preparation of these?
Physical or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse.
Would you like to discuss this isse with your provider?
Family Health History
Father:
Age or age at passing?
Any significant health problems?
Mother:
Age or age at passing?
Any significant health problems?
Siblings:
Please list number of siblings, their age(s), gender(s), and any significant health problems
Children:
Please list number of children, their age(s), gender(s), and any significant health problems
Grandparents:
Please list your grandparent's age(s) or ages at the time of their passing, and any significant health problems
Mental health
Is stress a major problem for you?
Do you feel depressed?
Do you panic when you stress?
Do you have problems with eating or your appetite?

Other
Do you cry frequently?
Have you ever attempted suicide?
Have you ever seriously thought about hurting yourself?
Do you have trouble sleeping?
Have you ever been to a counselor?
Women Only:
Age at onset of menstruation?
Date of last menstruation?

MonthDayYear
Date
Period every number of days?
Heavy periods, irregularity, spotting, pain, or discharge?
Number of pregnancies?
Number of live births?
Are you pregnant or breastfeeding?
Have you had a D&C, hysterectomy, or Cesarean?
Any urinary tract, bladder, or kidney infections within the last year?
Any blood in your urine?
Any problems with control of urination?
Any hot flashes or sweating at night?
Do you have menstrual tension, pain, bloating, irritablility, or other symptoms at or around time of period?
Experienced any recent breast tenderness, lumps, or nipple discharge?
Date of last pap and rectal exam?

MonthDayYear
Date
Men Only:
Do you usually get up to urinate during the night?
If yes, number of times?
Do you feel pain or burning with urination?
Any blood in your urine?
Do you feel burning discharge from penis?
Has the force of your urination decreased?
Have you had any kidney, bladder, or prostate infections within the last 12 months?
Do you have any problems emptying your bladder completely?
Any difficulty with erection or ejaculation?
Any testicle pain or swelling?
Date of last prostate or rectal exam?

MonthDayYear
Date
Other problems:
Check if you have or have had, any symptoms in the following areas to a significant degree and briefly explain.
Recent changes in:
Please describe any selections for the previous two questions:
Signature
Date

MonthDayYear
Date
Should be Empty:

Health History

Personal Health History

HEALTH HABITS AND PERSONAL SAFETY

Family Health History