HEALTH HISTORY

TODAY’S DATE:

Please complete this field.

PATIENT INFORMATION

Patient First Name

Please complete this field.

Patient Last Name

Please complete this field.

DOB:

Please complete this field.

PREVIOUS OR REFERRING DOCTOR:

Please complete this field.

Preferred Pharmacy:

Please complete this field.

Date of last physical exam:

Please complete this field.

PERSONAL HEALTH HISTORY

Immunizations and dates:

Tetanus

Please mark this checkbox.

Date:

Please complete this field.

Pneumonia

Please mark this checkbox.

Date:

Please complete this field.

Hepatitis

Please mark this checkbox.

Date:

Please complete this field.

Influenza

Please mark this checkbox.

Date:

Please complete this field.

MMR

Please mark this checkbox.

Date:

Please complete this field.

COVID-19

Please mark this checkbox.

Date:

Please complete this field.

Other

Please mark this checkbox.

Date:

Please complete this field.

LIST ANY MEDICAL PROBLEMS DIAGNOSED BY A PROVIDER

Please complete this field.

SURGERIES

Year

Please complete this field.

Reason

Please complete this field.

Hospital

Please complete this field.

Year

Please complete this field.

Reason

Please complete this field.

Hospital

Please complete this field.

Year

Please complete this field.

Reason

Please complete this field.

Hospital

Please complete this field.

Year

Please complete this field.

Reason

Please complete this field.

Hospital

Please complete this field.

OTHER HOSPITALIZATIONS

Year

Please complete this field.

Reason

Please complete this field.

Hospital

Please complete this field.

Year

Please complete this field.

Reason

Please complete this field.

Hospital

Please complete this field.

Year

Please complete this field.

Reason

Please complete this field.

Hospital

Please complete this field.

Year

Please complete this field.

Reason

Please complete this field.

Hospital

Please complete this field.

MEDICATIONS

Medication

Please complete this field.

Strength

Please complete this field.

Frequency Taken

Please complete this field.

Medication

Please complete this field.

Strength

Please complete this field.

Frequency Taken

Please complete this field.

Medication

Please complete this field.

Strength

Please complete this field.

Frequency Taken

Please complete this field.

Medication

Please complete this field.

Strength

Please complete this field.

Frequency Taken

Please complete this field.

Medication

Please complete this field.

Strength

Please complete this field.

Frequency Taken

Please complete this field.

ALLERGIES TO MEDICATIONS

Medication

Please complete this field.

Reaction

Please complete this field.

Medication

Please complete this field.

Reaction

Please complete this field.

Medication

Please complete this field.

Reaction

Please complete this field.

Medication

Please complete this field.

Reaction

Please complete this field.

Medication

Please complete this field.

Reaction

Please complete this field.

Medication

Please complete this field.

Reaction

Please complete this field.

HEALTH HABITS

Exercise

Sedentary

Yes

Please select an option.

Mild exercise

Yes

Please select an option.

Occasional vigorous exercise

Yes

Please select an option.

Regular vigorous exercise

Yes

Please select an option.

Diet

Are you dieting?

Yes

Please select an option.

If yes, are you on a physician prescribed medical diet?

Yes

Please select an option.

# of meals you eat in an average day?

Please complete this field.

Alcohol / Tobacco

Do you drink alcohol?

Yes

Please select an option.

How many drinks per week?

Please complete this field.

Do you use tobacco?

Yes

Please select an option.

Cigarettes

Please mark this checkbox.

pks./day:

Please complete this field.

Chew

Please mark this checkbox.

#/day:

Please complete this field.

Pipe

Please mark this checkbox.

#/day:

Please complete this field.

Cigars

Please mark this checkbox.

#/day:

Please complete this field.

# of years:

Please complete this field.

Or year quit:

Please complete this field.

Recreational Drugs

Do you currently use recreational or street drugs?

Yes

Please select an option.

Have you ever given yourself street drugs with a needle?

Yes

Please select an option.

PERSONAL SAFETY

Do you live alone?

Yes

Please select an option.

Do you have frequent falls?

Yes

Please select an option.

Do you have vision or hearing loss?

Yes

Please select an option.

Is stress a major problem for you?

Yes

Please select an option.

Do you feel depressed?

Yes

Please select an option.

Do you panic when stressed?

Yes

Please select an option.

Do you have problems with eating or your appetite?

Yes

Please select an option.

Do you cry frequently?

Yes

Please select an option.

Have you ever attempted suicide?

Yes

Please select an option.

Have you ever seriously thought about hurting yourself?

Yes

Please select an option.

Do you have trouble sleeping?

Yes

Please select an option.

Have you ever been to a counselor?

Yes

Please select an option.

WOMEN’S HEALTH (IF APPLICABLE)

Age at onset of menstruation:

Please complete this field.

Date of last menstruation:

Please complete this field.

Period every

Please complete this field.

Heavy periods, irregularity, spotting, pain, or discharge?

Yes

Please select an option.

Number of pregnancies:

Please complete this field.

Number of live births:

Please complete this field.

Are you pregnant or breastfeeding?

Yes

Please select an option.

Have you had a D&C, hysterectomy, or Cesarean?

Yes

Please select an option.

Any urinary tract, bladder, or kidney infections within the last year?

Yes

Please select an option.

Any blood in your urine?

Yes

Please select an option.

Any problems with control of urination?

Yes

Please select an option.

Any hot flashes or sweating at night?

Yes

Please select an option.

Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?

Yes

Please select an option.

Experienced any recent breast tenderness, lumps, or nipple discharge?

Yes

Please select an option.

Date of last pap and rectal exam?

Please complete this field.

MEN’S HEALTH (IF APPLICABLE)

Do you usually get up to urinate during the night?

Yes

Please select an option.

If yes, # of times

Please complete this field.

Do you feel pain or burning with urination?

Yes

Please select an option.

Do you usually get up to urinate during the night?

Yes

Please select an option.

Any blood in your urine?

Yes

Please select an option.

Do you feel burning discharge from penis?

Yes

Please select an option.

Has the force of your urination decreased?

Yes

Please select an option.

Have you had any kidney, bladder, or prostate infections within the last 12 months?

Yes

Please select an option.

Do you have any problems emptying your bladder?

Yes

Please select an option.

Any difficulty with erection or ejaculation?

Yes

Please select an option.

Any testicle pain or swelling?

Yes

Please select an option.

Date of last prostate and rectal exam?

Please complete this field.

HEALTH HISTORY

PATIENT INFORMATION

PATIENT INFORMATION

PERSONAL HEALTH HISTORY

PERSONAL HEALTH HISTORY

Immunizations and dates:

SURGERIES

SURGERIES

OTHER HOSPITALIZATIONS

OTHER HOSPITALIZATIONS

MEDICATIONS

MEDICATIONS

ALLERGIES TO MEDICATIONS

ALLERGIES TO MEDICATIONS

HEALTH HABITS

HEALTH HABITS

Exercise

Diet

Alcohol / Tobacco

Recreational Drugs

PERSONAL SAFETY

PERSONAL SAFETY

FAMILY HEALTH HISTORY

FAMILY HEALTH HISTORY

Father

Mother

Sibling(s)

Children(s)

Grandparent(s)

MENTAL HEALTH

MENTAL HEALTH

WOMEN’S HEALTH (IF APPLICABLE)

WOMEN’S HEALTH (IF APPLICABLE)

MEN’S HEALTH (IF APPLICABLE)

MEN’S HEALTH (IF APPLICABLE)

OTHER PROBLEMS / SYMPTOMS

OTHER PROBLEMS / SYMPTOMS

Recent changes in: