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
Normal
Abnormal
Mammogram
Normal
Abnormal
Colonoscopy/Sigmoid
Normal
Abnormal
Pap Smear
Normal
Abnormal
Bone Density
Normal
Abnormal
List your medications
1
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Last Tetanus Booster or TdaP:
Last Pnuemovax (Pneumonia):
Last Flu Vaccine:
Last Prevnar:
Last Zoster Vaccine (Shingles):
2
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:
Family Medical History
Mother
Father
Child
Maternal GM
Maternal GF
Paternal GM
Paternal GF
Alcohol/Drug Abuse
3
4
5
6
7
8
9
Asthma
10
11
12
13
14
15
16
Emphysema (COPD)
17
18
19
20
21
22
23
Depression / Anxiety
24
25
26
27
28
29
30
Bipolar / Suicidal
31
32
33
34
35
36
37
Diabetes
38
39
40
41
42
43
44
Early Death
45
46
47
48
49
50
51
Heart Disease
52
53
54
55
56
57
58
High Cholesterol
59
60
61
62
63
64
65
High Blood Pressure
66
67
68
69
70
71
72
Kidney Disease
73
74
75
76
77
78
79
Stroke
80
81
82
83
84
85
86
Thyroid Disease
87
88
89
90
91
92
93
Migraines
94
95
96
97
98
99
100
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
Submit
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