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Health History Questionnaire Form
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1
Basic Details
2
PERSONAL DETAILS
3
Eating Habits & Family Details
4
FAMILY HEALTH HISTORY
5
Other Problems
PERSONAL DETAILS
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Last Name
*
First Name
*
Middle Name
*
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E-mail
*
Phone Number
*
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Gender
*
Male
Female
Do not wish to specify
Date of Birth
*
Marital Status
*
Single
Have a Partner
Married
Separated
Divorced
Widowed
HEALTH HISTORY
HEALTH HISTORY
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Previous or Referring Doctor's Name
Date of Last Physical Exam
Childhood Illness (If Any)
Measles
Mumps
Rubella
Chickenpox
Rheumatic Fever
Polio
Immunizations and dates:
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Tetanus
Tetanus
Tetanus Date
Pneumonia
Pneumonia
Pneumonia Date
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Hepatitis
Hepatitis
Hepatitis Date
Chickenpox
Chickenpox
Chickenpox Date
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Influenza
Influenza
Influenza Date
MMR
MMR
(Measles, Mumps, Rubella)
MMR Date
Mention Any Medical Problems That Other Doctors Have Diagnosed
Mention Any Medical Problems That Other Doctors Have Diagnosed
Surgeries:
SURGERIES
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Year
Reason
Hospital
SURGERIES
Other Hospitalizations:
OTHER HOSPITALIZATIONS
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Year
Reason
Hospital
OTHER HOSPITALIZATIONS
Have You Ever Had a Blood Transfusion?
*
Yes
No
Medical History
Mention Your Prescribed Drugs & Over-the-Counter Medicines, such as Vitamins & Inhaler:
MEDICAL HISTORY
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Drug / Medicine Name
Strength
Frequency Taken
MEDICAL HISTORY
Allergies to medications :
ALLERGIES DRUGS DETAILS
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Drug / Medicine Name
Reaction You Have
ALLERGIES DRUGS DETAILS
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HEALTH HABITS & PERSONAL SAFETY
*All Questions Contained in This Questionnaire are Optional and will be Kept Strictly Confidential.
Physical Exercise
Sedentary (no exercise)
Mild Exercise (climbing stairs, walk three blocks, golf, etc.)
Occasional Exercise (vigorous workout or recreational activity, less than 4 times / week for 30 mins.)
Vigorous Exercise (workout or recreational activity, 4 times / week for 30 mins.)
Diet
DIET
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Are You Dieting?
Yes
No
If Yes, are You on a Physician Prescribed Medical Diet?
Yes
No
Number of Meals You Eat on an Average Day?
1
2 to 3
More than 3
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Salt Intake
High
Medium
Low
Caffeine Intake
None
Coffee
Tea
Cola
Fat Intake
High
Medium
Low
No. of Cups / Cans Per Day?
Alcohol
ALCOHOL
Do You Drink Alcohol?
*
Yes
No
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If Yes, What Kind?
Are You Concerned About the Amount You Drink?
Yes
No
Have You Ever Experienced Blackouts?
Yes
No
Do You Drive After Drinking?
Yes
No
How Many Drinks Per Week?
Have You Considered Stopping?
Yes
No
Are You Prone to “Binge” Drinking?
Yes
No
Tobacco
TOBACCO
Do you use tobacco?
*
Yes
No
Tobacco
Cigarettes Packs / Day
Cigars - Number / Day
Smoking Pipe (Times / Day)
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Chewing Tobacco (Number / Day)
Since How Many Years
Or Quit Since
Drugs
DRUGS
Drugs
Do You Currently Use Recreational or Street Drugs?
*
Yes
No
Have You Ever Given Yourself Street Drugs with a Needle?
*
Yes
No
Sex
SEX
Sex
Are You Sexually Active?
*
Yes
No
Any Discomfort with Intercourse?
*
Yes
No
Illnesses related to the Human Immunodeficiency Virus (HIV), including AIDS, are significant public health concerns. Common risk factors include Intravenous Drug Use and Unprotected Sexual Activity. Would you like to discuss your risk with your healthcare provider?
*
Yes
No
Personal Safety
PERSONAL SAFETY
Personal Safety
Do You Live Alone?
*
Yes
No
Do You Have Vision or Hearing Loss?
*
Yes
No
Do You Have Frequent Falls?
*
Yes
No
Do You Have an Advance Directive or Living Will?
*
Yes
No
Would You Like Information on The Preparation of These?
*
Yes
No
Physical and Mental Abuse are Major Public Health Concerns in This Country and may Include Verbal Threats, Physical Harm, or Sexual Abuse. Would You Like to Discuss This With Your Healthcare Provider?
*
Yes
No
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FAMILY HEALTH HISTORY
Father
FATHER
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Age
Significant Health Problems
Mother
MOTHER
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Age
Significant Health Problems
Sibling(s)
Sibling(s)
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Gender
Male
Female
Significant Health Problems
Sibling(s)
Children
CHILDREN
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Children
Boy
Girl
Significant Health Problems
CHILDREN
Maternal
MATERNAL
Grand-Father
GRAND-FATHER
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Age
Significant Health Problems
Grand-Mother
GRAND-MOTHER
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Age
Significant Health Problems
Paternal
PATERNAL
Grand-Father
GRAND-FATHER
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Age
Significant Health Problems
Grand-Mother
GRAND-MOTHER
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Age
Significant Health Problems
MENTAL HEALTH
MENTAL HEALTH
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Is Stress a Major Problem for You?
*
Yes
No
Do You Feel Depressed?
*
Yes
No
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Do You Panic When Stressed?
*
Yes
No
Do You Have Problems with Eating or Your Appetite?
*
Yes
No
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Do You Cry Frequently?
*
Yes
No
Have You Ever Attempted Suicide?
*
Yes
No
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Have You Ever Seriously Thought About Hurting Yourself?
*
Yes
No
Do You Have Trouble Sleeping?
*
Yes
No
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Have You Ever been to a Counselor?
*
Yes
No
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OTHER PROBLEMS
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
OTHER PROBLEMS
Other Problems
Recent changes in:
Other Problems
Skin
Head/Neck
Ears
Nose
Throat
Lungs
Chest/Heart
Back
Intestinal
Bladder
Bowel
Circulation
Weight
Energy Level
Ability to Sleep
Other Pain / Discomfort
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Age at Onset of Menstruation
Date of Last Menstruation
Period Cycle (Days)
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Heavy Periods, Irregularity, Spotting, Pain, or Discharge?
Yes
No
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Are You Pregnant or Breast-feeding?
Yes
No
Number of Pregnancies
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Number of Live Births
Have You Had a D&C, Hysterectomy, or Cesarean?
Yes
No
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Any Urinary Tract, Bladder, or Kidney Infections within The Last Year?
Yes
No
Any Blood in Your Urine?
Yes
No
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Any Problems with Control of Urination?
Yes
No
Any Hot Flashes or Sweating at Night?
Yes
No
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Do You Have Menstrual Tension, Pain, Bloating, Irritability, or Other Symptoms During Period?
Yes
No
Date of Last Pap & Rectal Exam?
Experienced Any Recent Breast Tenderness, Lumps, or Nipple Discharge?
Yes
No
Male Only
Do You Usually Get up to Urinate During The Night?
Yes
No
If Yes, Number of Times You Urinate
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Do You Feel Pain Or Burning With Urination?
Yes
No
Any Blood in Your Urine?
Yes
No
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Do You Feel Burning Discharge From Penis?
Yes
No
Has The Force of Your Urination Decreased?
Yes
No
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Have You Had Any Kidney, Bladder, or Prostate Infections Within The Last 12 Months?
Yes
No
Do You Have Any Problems Emptying Your Bladder Completely?
Yes
No
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Any difficulty with erection or ejaculation?
Yes
No
Any Testicle Pain or Swelling?
Yes
No
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Date of Last Prostate and Rectal Exam?
Patient
Patient Printed Name
*
Date
Patient Signature
*
Clear Signature
Guardian
Do You Have a Guardian ?
*
Yes
No
Guardian Printed Name
*
Guardian / Legal Representative
*
Date
Guardian Signature
*
Clear Signature
Submit
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