Health History Questionnaire

Title Page

Hospital/Clinic
Conducted on
Prepared by
Location

Medical History

General Information

Name
Birth date
Age
Sex
Contact phone numbers
Briefly describe your present symptoms
Please list other physicians you have seen in the last 12 months, and for what reason.

Current Medications

Drug allergies?
To what:
Medications that you are now taking. Include non-prescription medications & vitamins or supplements.

Medical History

Do you now or have you ever had:
Diabetes
High blood pressure
High cholesterol
Hypothyroidism
Goiter
Cancer
Type:
Leukemia
Psoriasis
Psychiatric condition
Type:
Angina
Heart problems
Heart murmur
Pneumonia
Pulmonary embolism
Asthma
Emphysema
Stroke
Epilepsy (seizures)
Cataracts
Glaucoma
Kidney disease
Kidney stones
Crohn’s disease
Colitis
Anemia
Jaundice
Hepatitis
Stomach or peptic ulcer
Varicose veins
Environmental allergies
Blood clots
Serious trauma
Sexually transmitted infection
Other:

Personal History

Childhood Illness
- Measles
- Mumps
- Rubella
- Chickenpox
- Rheumatic Fever
- Polio
- None
Immunizations?
Tetanus
Date of immunization
Pneumonia
Date of immunization
Hepatitis A
Date of immunization
Hepatitis B
Date of immunization
Chickenpox
Date of immunization
Influenza
Date of immunization
MMR (Measles, Mumps, Rubella)
Date of immunization
Meningococcal
Date of immunization
Any surgeries?
Please provide the year/reason/hospital
Have you ever had a blood transfusion?
Where were you born & raised?
What is your highest education?
Marital status
- Never married
- Married
- Divorced
- Separated
- Widowed
- Partnered/significant other
What is your current or past occupation?

Family History

Family history is:
Please indicate if your family has a history of the following: (include only parents, grandparents, siblings, and children)
Alcohol Abuse
Anemia
Anesthetic Complication
Arthritis
Asthma
Bladder Problems
Bleeding Disease
Breast Cancer
Colon Cancer
Depression
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Leukemia
Lung/Respiratory Disease
Migraines
Osteoporosis
Other Cancer
Rectal Cancer
Seizures/Convulsions
Severe Allergy
Stroke/CVA of the Brain
Thyroid Problems
Mother, Grandmother, or Sister developed heart disease before the age of 65
Father, Grandfather, or Brother developed heart disease before the age of 55
NONE of the Above

Review of Systems

Please indicate with a check (√) any current problems you have below.

Constitutional

Fevers/chills/sweats
Unexplained weight loss/gain
Fatigue/weakness
Excessive thirst or urination
Other
Please describe other

Cardiovascular

Chest pain/discomfort
Leg pain with exercise
Heart murmur or heart problems
Palpitations
Other

Please describe other

Chest

Breast lump/discharge
Other
Please describe other

Ears/Nose/Throat/Mouth

Difficulty hearing/ringing in ears
Hay fever/allergies
Problems with teeth/gums
Difficulty swallowing
Difficulty with speech
Other
Please describe other

Endocrine

Hypothyroid
Hyperthyroid
Abnormal hormone levels
Abnormal blood glucose levels
Other
Please describe other

Eyes

Changes in vision
Farsighted
Nearsighted
Other
Please describe other

Gastrointestinal

Abdominal pain
Blood in bowel movement
Nausea/vomiting/diarrhea
Other
Please describe other

Genitourinary

Nighttime urination
Incontinence
Sexual function problems
Discharge from penis
Other
Please describe other

Gynecological

Abnormal vaginal bleeding
Problems with conceiving
Problems with contraception
Vaginal discharge
Vaginal odor
Painful intercourse
Other
Please describe other

Lymphatic/Blood

Unexplained lumps
Easy bruising/bleeding
Anemia
Other
Please describe other

Musculo-skeletal

Muscle/joint pain
Arthritis
Other
Please describe other

Neurological

Headaches
Dizziness/light-headedness
Numbness
Memory loss
Loss of coordination
Epilepsy or convulsive seizures
Other
Please describe other

Psychiatric

Anxiety/stress
Problems with sleep
Depression
Suicidal ideations
Other
Please describe other

Respiratory

Cough/wheeze
Difficulty breathing
Asthma
COPD
Sleep apnea
Other
Please describe other

Skin

Rash or mole change(s)
Psoriasis
Eczema
Other
Please describe other

Women/Men's Health

Male or Female?
Gynecologic History
Do you have a period every month?
Number of days of flow
Menstrual cramps
Date of last PAP smear
Last PAP smear result
Have you ever had an abnormal PAP smears?
If yes, explain clinical history (including test location, date, what was done) for any abnormal PAP smear:
Number of pregnancies
Are you presently trying to become pregnant or will be trying soon?
Gynecologic symptoms:
• Abnormal menstrual bleeding
• Missed periods
• Night sweats
• Hot flashes
• Vaginal dryness
• History of prescription hormone use
• Mood changes associated with period
• Insomnia
Have you ever had a mammogram?
If applicable, indicate the date and result of your last mammogram:
Do you usually get up to urinate during the night?
Do you feel pain or burning with urination?
Any blood in our urine?
Do you feel burning discharge from penis?
Has the force of your urination decreased?
Have you had any kidney, bladder, or prostrate infections within the last 12 months?
Do you have any problems emptying your bladder completely?
Any difficulty with erection or ejaculation?
Any testicle pain or swelling?
Date of last prostate and rectal exam

Sexual History

Have you ever been sexually active?
Are you currently sexually active?
Complete the following questions if you are sexually active.
Are you currently having sexual relations with one partner or multiple partners?
Number of partners in last year
Are you in a monogamous relationship?
Are/Is your sexual partner(s)
Do you and your partner use contraceptive and/or protective methods?
Have you ever had a sexually transmitted illness (STI) (i.e. HPV, Herpes, Chlamydia, Gonorrhea or other)? <br>
List STI:
Treated