Health History Questionnaire

Choose an office: *

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Date:

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All questions contained in this questionnaire are strictly confidential and will become part of your medical record

Patient First Name

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Patient Last Name

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Sex:

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DOB:

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Marital status:

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Previous or referring doctor:

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Date of last physical exam:

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PERSONAL HEALTH HISTORY

Childhood illness:

Please select an option.

Immunizations and dates:

Tetanus

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Pneumonia

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Hepatitis

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Chickenpox

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Influenza

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MMR Measles, Mumps, Rubell

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List any medical problems that other doctors have diagnosed

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Surgeries:

Year:

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Reason

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Hospital

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Year:

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Reason

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Hospital

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Year:

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Reason

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Hospital

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Year:

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Reason

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Hospital

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Other hospitalizations:

Year:

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Reason

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Hospital

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Year:

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Reason

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Hospital

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Year:

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Reason

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Hospital

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Year:

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Reason

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Hospital

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Have you ever had a blood transfusion?

Please select an option.

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Name the Drug

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Strength

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Frequency Taken

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Name the Drug

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Strength

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Frequency Taken

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Name the Drug

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Strength

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Frequency Taken

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Name the Drug

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Strength

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Frequency Taken

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Allergies to medications:

Name the Drug

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Reaction You Had

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Name the Drug

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Reaction You Had

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Name the Drug

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Reaction You Had

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Name the Drug

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Reaction You Had

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HEALTH HABITS AND PERSONAL SAFETY

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.

Exercise

Sedentary (No exercise

Mild exercise (i.e., climb stairs, walk 3 blocks, golf)

Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)

Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)

Diet

Are you dieting?

Please select an option.

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

Please select an option.

# of meals you eat in an average day?

Rank salt intake

Please select an option.

Rank fat intake

Please select an option.

Caffeine

None

Coffee

Tea

Cola

# of cups/cans per day?

Please complete this field.

Alcohol

Do you drink alcohol?

Please select an option.

If yes, what kind?

Please complete this field.

How many drinks per week?

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Are you concerned about the amount you drink?

Please select an option.

Have you considered stopping?

Please select an option.

Have you ever experienced blackouts?

Please select an option.

Are you prone to “binge” drinking?

Please select an option.

Do you drive after drinking?

Please select an option.

Tobacco

Do you use tobacco?

Please select an option.

Cigarettes – pks./day

Chew - #/day

Pipe - #/day

Cigars - #/day

# of years

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Or year quit

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Drugs

Do you currently use recreational or street drugs?

Please select an option.

Have you ever given yourself street drugs with a needle?

Please select an option.

Sex

Are you sexually active?

Please select an option.

If yes, are you trying for a pregnancy?

Please select an option.

If not trying for a pregnancy list contraceptive or barrier method used: Any discomfort with intercourse?

Please select an option.

Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?

Please select an option.

Personal Safety

Do you live alone?

Please select an option.

Do you have frequent falls?

Please select an option.

Do you have vision or hearing loss?

Please select an option.

Do you have an Advance Directive or Living Will?

Please select an option.

Would you like information on the preparation of these?

Please select an option.

Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?

Please select an option.

FAMILY HEALTH HISTORY

Father

Age

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Significant Health Problems

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Mother

Age

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Significant Health Problems

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Sibling

Sex:

Please select an option.

Age

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Significant Health Problems

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Sibling

Sex:

Please select an option.

Age

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Significant Health Problems

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Sibling

Sex:

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Age

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Significant Health Problems

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Children

Sex

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Age

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Significant Health Problems

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Children

Sex

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Age

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Significant Health Problems

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Children

Sex

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Age

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Significant Health Problems

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Grandmother Maternal

Age

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Significant Health Problems

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Grandfather Maternal

Age

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Significant Health Problems

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Grandmother Paternal

Age

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Significant Health Problems

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Grandfather Paternal

Age

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Significant Health Problems

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MENTAL HEALTH

Is stress a major problem for you?

Please select an option.

Do you feel depressed?

Please select an option.

Do you panic when stressed?

Please select an option.

Do you have problems with eating or your appetite?

Please select an option.

Do you cry frequently?

Please select an option.

Have you ever attempted suicide?

Please select an option.

Have you ever seriously thought about hurting yourself?

Please select an option.

Do you have trouble sleeping?

Please select an option.

Have you ever been to a counselor?

Please select an option.

WOMEN ONLY

Age at onset of menstruation:

Please complete this field.

Date of last menstruation:

Please complete this field.

Period on every what days?

Please complete this field.

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

Please select an option.

Number of pregnancies

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Number of live births

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Are you pregnant or breastfeeding?

Please select an option.

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

Please select an option.

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

Please select an option.

Any blood in your urine?

Please select an option.

Any problems with control of urination?

Please select an option.

Any hot flashes or sweating at night?

Please select an option.

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

Please select an option.

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

Please select an option.

Date of last pap and rectal exam?

Please complete this field.

MEN ONLY

Do you usually get up to urinate during the night?

Please select an option.

If yes, # of times

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Do you feel pain or burning with urination?

Please select an option.

Any blood in your urine?

Please select an option.

Do you feel burning discharge from penis?

Please select an option.

Has the force of your urination decreased?

Please select an option.

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

Please select an option.

Do you have any problems emptying your bladder completely

Please select an option.

Any difficulty with erection or ejaculation?

Please select an option.

Any testicle pain or swelling?

Please select an option.

Date of last prostate and rectal exam?

Please complete this field.

Health History Questionnaire

All questions contained in this questionnaire are strictly confidential and will become part of your medical record

PERSONAL HEALTH HISTORY

PERSONAL HEALTH HISTORY

Immunizations and dates:

Surgeries:

Other hospitalizations:

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Allergies to medications:

HEALTH HABITS AND PERSONAL SAFETY

HEALTH HABITS AND PERSONAL SAFETY

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.

Exercise

Diet

# of meals you eat in an average day?

Caffeine

Alcohol

Tobacco

Drugs

Sex

Personal Safety

FAMILY HEALTH HISTORY

FAMILY HEALTH HISTORY

Father

Mother

Sibling

Sibling

Sibling

Children

Children

Children

Grandmother Maternal

Grandfather Maternal

Grandmother Paternal

Grandfather Paternal

MENTAL HEALTH

MENTAL HEALTH

WOMEN ONLY

WOMEN ONLY

MEN ONLY

MEN ONLY

OTHER PROBLEMS

OTHER PROBLEMS

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.

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