Health History Questionnaire

Patient Gender

Patient Name

First NameLast Name

Patient Birth Date

Birth Date

Patient Height (in cm's)

Patient Weight (in kg's)

Patient E-Mail

Reason for seeing the doctor:

ex: Routine Check-up

Please list if you have any drug allergies

ex: Penicilin

Have you ever had (Please check all that apply)

Please list if you have other illnesses:

Please list any operations and dates of each:

Please list your current medications

Exercise

Eating following a diet

Alcohol Consumption

Caffeine Consumption

Do you smoke?

Include other comments regarding your Medical History

Healthy & Unhealthy Habits