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Health History Questionnaire Form
Please enable JavaScript in your browser to complete this form.
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Last Name
*
First Name
*
Middle Name
*
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Gender
*
Male
Female
Marital status
*
Single
Partnered
Married
Separated
Divorced
Widowed
Previous or referring doctor
DOB
*
Phone Number
*
Date of last physical exam
PERSONAL HEALTH HISTORY
Childhood illness
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
List any medical problems that other doctors have diagnosed
Surgeries:
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Year
Year
Reason
Reason
Hospital
Hospital
Other hospitalizations:
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Year
Year
Reason
Reason
Hospital
Hospital
Have you ever had a blood transfusion?
*
Yes
No
List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers :
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Name the drug
Name the drug
Name the drug
Name the drug
Strength
Strength
Strength
Strength
Frequency Taken
Frequency Taken
Frequency Taken
Frequency Taken
Allergies to medications :
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Name the drug
Name the drug
Reaction you had
Reaction you had
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
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Are you dieting?
Yes
No
If yes, are you on a physician prescribed medical diet?
Yes
No
# of meals you eat in an average day?
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Rank salt intake
Hi
Med
Low
Caffeine
None
Coffee
Tea
Cola
Rank fat intake
Hi
Med
Low
# of cups/cans per day?
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
Do you use tobacco?
*
Yes
No
Tobacco
Cigarettes –pks./day
# of years
Chew - #/day
Or year quit
Pipe - #/day
Cigars - #/day
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
Are you sexually active?
*
Yes
No
If yes, are you trying for a pregnancy?
Yes
No
If not trying for a pregnancy list contraceptive or barrier method used:
Any discomfort with intercourse?
*
Yes
No
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?
*
Yes
No
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/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?
*
Yes
No
FAMILY HEALTH HISTORY
Father
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Age
SIGNIFICANT HEALTH PROBLEMS
Mother
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Age
SIGNIFICANT HEALTH PROBLEMS
Sibling
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Sibling
M
F
SIGNIFICANT HEALTH PROBLEMS
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Sibling
M
F
SIGNIFICANT HEALTH PROBLEMS
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Sibling
M
F
SIGNIFICANT HEALTH PROBLEMS
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Sibling
M
F
SIGNIFICANT HEALTH PROBLEMS
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Sibling
M
F
SIGNIFICANT HEALTH PROBLEMS
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Sibling
M
F
SIGNIFICANT HEALTH PROBLEMS
Children
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Children
M
F
SIGNIFICANT HEALTH PROBLEMS
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Children
M
F
SIGNIFICANT HEALTH PROBLEMS
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Children
M
F
SIGNIFICANT HEALTH PROBLEMS
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Children
M
F
SIGNIFICANT HEALTH PROBLEMS
Grandmother Maternal
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Age
SIGNIFICANT HEALTH PROBLEMS
Grandfather Maternal
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Age
SIGNIFICANT HEALTH PROBLEMS
Grandmother Paternal
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Age
SIGNIFICANT HEALTH PROBLEMS
Grandfather Paternal
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Age
SIGNIFICANT HEALTH PROBLEMS
MENTAL HEALTH
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Is stress a major problem for you?
*
Yes
No
Do you feel depressed?
*
Yes
No
Do you panic when stressed?
*
Yes
No
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Do you have problems with eating or your appetite?
*
Yes
No
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
Have you ever been to a counselor?
*
Yes
No
WOMEN ONLY
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Age at onset of menstruation:
Date of last menstruation:
Period every ___ days
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Heavy periods, irregularity, spotting, pain, or discharge?
Yes
No
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Number of pregnancies
Are you pregnant or breastfeeding?
Yes
No
Any urinary tract, bladder, or kidney infections within the last year?
Yes
No
Any problems with control of urination?
Yes
No
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?
Yes
No
Date of last pap and rectal exam?
Number of live births
Have you had a D&C, hysterectomy, or Cesarean?
Yes
No
Any blood in your urine?
Yes
No
Any hot flashes or sweating at night?
Yes
No
Experienced any recent breast tenderness, lumps, or nipple discharge?
Yes
No
MEN ONLY
Male Only
Do you usually get up to urinate during the night?
Yes
No
Do you feel pain or burning with urination?
Yes
No
Do you feel burning discharge from penis?
Yes
No
Have you had any kidney, bladder, or prostate infections within the last 12 months?
Yes
No
Any difficulty with erection or ejaculation?
Yes
No
Date of last prostate and rectal exam?
If yes, # of times _____
Any blood in your urine?
Yes
No
Has the force of your urination decreased?
Yes
No
Do you have any problems emptying your bladder completely?
Yes
No
Any testicle pain or swelling?
Yes
No
OTHER PROBLEMS
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
Other Problems
Skin
Head/Neck
Ears
Nose
Throat
Lungs
Chest/Heart
Back
Intestinal
Bladder
Bowel
Circulation
Recent changes in:
Weight
Energy level
Ability to sleep
Other pain/discomfort
Patient
Patient Printed Name
Patient Signature
Clear Signature
Date
Guardian
Do you have Guardian ?
*
Yes
No
Guardian Printed Name
*
Guardian Signature
*
Clear Signature
Guardian / Legal Representative
*
Date
Submit
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