Patient History Questionnaire
Date
Month Day Year
Date
Name
First Name Last Name
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
Month Day Year
Date
Age
Marital Status
Single Married Separated Divorced Widowed
Gender
Male Female
Name of Referring Doctor
Prefix First Name Last Name Suffix
Name of Primary Care Physician
Prefix First Name Last Name Suffix
Social / Work History
Current Occupation Status
Employed Unemployed LOA Other
Occupation or Last Occupation
Are you working on night shifts?
Yes No
Name of Employer or Business
Highest Education Attainmened
Please describe your chief concern
How long have you had this concern?
Are you taking any medications?
Yes No

Health Maintenance Information

	Date	Facility/Provider	Abnormal Result?
Cholesterol
Mammogram
Colonoscopy/Sigmoid
Pap Smear
Bone Density

List your medications
Not Satisfied Somewhat Satisfied Satisfied Very Satisfied
Last Tetanus Booster or TdaP:
Last Pnuemovax (Pneumonia):
Last Flu Vaccine:
Last Prevnar:
Last Zoster Vaccine (Shingles):

	Type	Current	Past	Comment
Alcoholism/Drug Abuse
Asthma
Cancer
Depression/Anxiety/Bipolar/Suicidal
Diabetes
Emphysema (COPD)
Heart Disease
High Blood Pressure (hypertension)
High Cholesterol
Hypothyroidism/Thyroid Disease
Renal (kidney) Disease
Migraine Headaches
Stroke
Other:
Other:

Please indicate the major surgeries that you had (if any)
Female Health History
Details
Date of Last Menstrual Cycle:
Age of First Menstruation:
Age of Menopause:
Total Number of Pregnancies:
Number of Live Births:
Pregnancy Complications:

	Details
Date of Last Menstrual Cycle:
Age of First Menstruation:
Age of Menopause:
Total Number of Pregnancies:
Number of Live Births:
Pregnancy Complications:

Family Medical History

	Mother	Father	Child	Maternal GM	Maternal GF	Paternal GM	Paternal GF
Alcohol/Drug Abuse
Asthma
Emphysema (COPD)
Depression / Anxiety
Bipolar / Suicidal
Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Migraines

Please Indicate which among your direct relatives has or had cancer
Do you smoke?
Yes No
Number sticks per day
How long have you been smoking?
Do you use recreational drugs such as marijuana?
Yes No
Do you drink alcohol?
Yes No
Sexually active?
Yes No
Sexual partners you have had
Male Female
Birth Control Methods
Condom Pill/Ring/Patch/Inj/IUD Vasectomy None Other
Review of Systems
Constitution
Activity change Appetite change Chills Diaphoresis Fatigue Fever Unexpected weight change
Eyes
Blurry vision/Double vision Cataracts/ Macular degeneration Glasses/Contacts/Blindness Glaucoma/Retinopathy Partial loss of vision/blind spots
Ears/Nose/Mouth/Throat
Dentures/Difficulty swallowing Hearing Loss/ringing in ears Prolonged Nose bleeds Voice change
Cardiovascular
Ankle Swelling /Varicosities Calf pain with/without exercise Chest pain with exertion/Exercise Chest pain/ Heart murmur Dyspnea on exertion/Syncope Irregular/Rapid heart rate Leg Pain/Cramping in legs at night
Respiratory
Asthma/ Anesthetic problems COPD/Pneumonia/Emphysema Coughing/coughing up blood Hoarsness/Obstructive Sleep Apnea Oxygen Dependent LPM Shortness of Breath with Exertion Shortness of breath /Wheezing Tuberculosis or exposure
Gastrointestinal
Abdominal pain/Blood in stool Black or Tarry stool Bloating/Diarrhea/Constipation Loss of appetite/Heartburn Nausea/Vomiting Ulcer disease/Pain after eating Vomited blood
Endocrine
Cold/Heat intolerance History of drug resistant infection
Integumentary (Skin)
New skin lesions/Skin Cancer Rash/Persistent itching Unhealed/Delayed healing of sores
Neurological
Migraines/Headache/Vertigo Temporary/Paralysis Arm/Leg/Face Tingling/Numbness Speech difficulties/Seizures
Musculoskeletal
Artificial knee or hip joint Back pain/Joint pain Degenerative/Osteoarthritis Muscle pain/Weakness/Cramps Rheumatoid Arthritis
Genitourinary
Impotence Incontinence /Difficulty Voiding Kidney stones Suprapubic/Indwelling Catheter Urgency/Blood in Urine
Psychiatric
Anxiety/Depression Confusion/Memory loss Difficulty sleeping
Heme/Lymphatic/Immune
Anemia/Low platelet count Bleeding disorder/Easy bleeding Easy bruising Lymphoma/Leukemia Frequent illnesses
Should be Empty:

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
Last Tetanus Booster or TdaP:
Last Pnuemovax (Pneumonia):
Last Flu Vaccine:
Last Prevnar:
Last Zoster Vaccine (Shingles):

Patient History Questionnaire