Patient History Questionnaire

Patient History Questionnaire
Date
MonthDayYear
Date
Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
MonthDayYear
Date
Age
Marital Status
SingleMarriedSeparatedDivorcedWidowed
Gender
MaleFemale
Name of Referring Doctor
PrefixFirst NameLast NameSuffix
Name of Primary Care Physician
PrefixFirst NameLast NameSuffix
Social / Work History
Current Occupation Status
EmployedUnemployedLOAOther
Occupation or Last Occupation
Are you working on night shifts?
YesNo
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?
YesNo
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?
YesNo
Number sticks per day
How long have you been smoking?
Do you use recreational drugs such as marijuana?
YesNo
Do you drink alcohol?
YesNo
Sexually active?
YesNo
Sexual partners you have had
MaleFemale
Birth Control Methods
CondomPill/Ring/Patch/Inj/IUDVasectomyNoneOther
Review of Systems
Constitution
Activity changeAppetite changeChillsDiaphoresisFatigueFeverUnexpected weight change
Eyes
Blurry vision/Double visionCataracts/ Macular degenerationGlasses/Contacts/BlindnessGlaucoma/RetinopathyPartial loss of vision/blind spots
Ears/Nose/Mouth/Throat
Dentures/Difficulty swallowingHearing Loss/ringing in earsProlonged Nose bleedsVoice change
Cardiovascular
Ankle Swelling /VaricositiesCalf pain with/without exerciseChest pain with exertion/ExerciseChest pain/ Heart murmurDyspnea on exertion/SyncopeIrregular/Rapid heart rateLeg Pain/Cramping in legs at night
Respiratory
Asthma/ Anesthetic problemsCOPD/Pneumonia/EmphysemaCoughing/coughing up bloodHoarsness/Obstructive Sleep ApneaOxygen Dependent LPMShortness of Breath with ExertionShortness of breath /WheezingTuberculosis or exposure
Gastrointestinal
Abdominal pain/Blood in stoolBlack or Tarry stoolBloating/Diarrhea/ConstipationLoss of appetite/HeartburnNausea/VomitingUlcer disease/Pain after eatingVomited blood
Endocrine
Cold/Heat intoleranceHistory of drug resistant infection
Integumentary (Skin)
New skin lesions/Skin CancerRash/Persistent itchingUnhealed/Delayed healing of sores
Neurological
Migraines/Headache/VertigoTemporary/Paralysis Arm/Leg/FaceTingling/NumbnessSpeech difficulties/Seizures
Musculoskeletal
Artificial knee or hip jointBack pain/Joint painDegenerative/OsteoarthritisMuscle pain/Weakness/CrampsRheumatoid Arthritis
Genitourinary
ImpotenceIncontinence /Difficulty VoidingKidney stonesSuprapubic/Indwelling CatheterUrgency/Blood in Urine
Psychiatric
Anxiety/DepressionConfusion/Memory lossDifficulty sleeping
Heme/Lymphatic/Immune
Anemia/Low platelet countBleeding disorder/Easy bleedingEasy bruisingLymphoma/LeukemiaFrequent illnesses
Should be Empty:

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

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