• Health History Questionnaire

    All questions contained in this questionnaire are strictly confidentialand will become part of your medical record.
  • DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital Status:
  • Date of Last Physical Exam:
     - -
    2 digit month, 2 digit day, 4 digit year

  • PERSONAL HEALTH HISTORY

  • Childhood Illness:
  • Immunizations and Dates: if known
    Rows
  • Any Past Operations or Surgeries:
  • Other Hospitalizations:
  • Emergency room Visits:
  • Have you ever had a blood transfusion?
  • List Your Prescribed Drugs and Over-the-Counter Drugs, Such as Vitamins and Inhalers:
  • Allergies to Medications:

  • FAMILY HEALTH HISTORY

  • Rows
  • Rows
  • Brothers and Sisters
    Rows
  • Grandparents (Mother’s Side)
    Rows
  • Grandparents (Father’s Side)
    Rows

  • HEALTH HABITS AND PERSONAL SAFETY

  • Exercise:

  • Exercise:

  • Diet:

  • Are you dieting?
  • If yes, are you on a physician prescribed medical diet?
  • Rank Salt Intake
  • Rank Fat Intake

  • Caffeine:

  • Caffeine:

  • Alcohol:

  • Do you drink alcohol?
  • 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?

  • Tobacco:

  • Do you use tobacco?

  • Drugs:

  • Do you currently use recreational or street drugs?
  • Have you ever given yourself street drugs with a needle?

  • Sex

  • Are you sexually active?
  • If yes, are you trying for a pregnancy?
  • 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 us about your risk of this illness?

  • Personal Safety:

  • 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 and/or mental abuse has 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 issue with us?

  • MENTAL HEALTH:

  • Is stress a major problem for you?
  • Do you feel depressed?
  • Do you panic when stressed?
  • Do you have problems with eating or your appetite?
  • 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?
  • Would you like to discuss this issue with us?

  • WOMEN ONLY

  • Date of last menstruation:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Heavy periods, irregularity, spotting, pain or discharge?
  • 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, irritability 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?
     - -
    2 digit month, 2 digit day, 4 digit year

  • MEN ONLY

  • Do you usually get up to urinate during the night?
  • 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 and rectal exam?
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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 read and remember that the following recommendations are very important to maintaining your health.

    • When in a car, wear your safety belt at all times.
    • While riding a motorcycle or bicycle, wear a helmet.
    • Always have functional smoke detectors and fire extinguishers in your home.
    • If you own a firearm, make sure that it is accessible only to you.
    • Take every precaution to ensure that children do not have access to a loaded firearm.
    • Keep the firearm and ammunition in separate locations.

    Thank You

  • Should be Empty: