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Health History Questionnaire
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Name:
Email:
Health History Questionnaire
First Name
Last Name
Age
Email
Address
City
State
Zip
Telephone #
Date of Birth
Select Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
PAST MEDICAL HISTORY
Have you:
If Yes:
Had any serious illnesses?
Please List:
Date:
No
Yes
Ever been hospitalized?
For what:
Date:
No
Yes
Had any surgeries?
Please List:
Date:
No
Yes
Had any broken bones?
Which ones:
No
Yes
Had any head injuries?
When:
No
Yes
Have you ever had:
Cancer?
No
Yes
Mumps?
No
Yes
High Blood Pressure?
No
Yes
Pneumonia?
No
Yes
Heart Disease?
No
Yes
High Cholesterol?
No
Yes
Tuberculosis?
No
Yes
Stroke?
No
Yes
Blood Clots?
No
Yes
Chicken Pox?
No
Yes
Diabetes?
No
Yes
Venereal Disease?
No
Yes
Measles?
No
Yes
Hepatitis?
No
Yes
MEDICATIONS
List the medications you are taking:
qD = Once Daily, BID = Twice Daily,
TID = Three Times Daily
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
qD
BID
TID
Other
List any over the counter drugs or vitamins you take:
ALLERGIES
Do you have any drug allergies?
If yes, to what?
No
Yes
What symptoms did you have?
FAMILY HISTORY
If living:
Age & Health Status:
If deceased:
Age @ death & cause:
Has any blood relative had:
Father:
Cancer?
No
Yes
Mother:
Tuberculosis?
No
Yes
Brother(s)
Diabetes?
No
Yes
Heart Disease?
No
Yes
Stroke?
No
Yes
Sister(s)
Seizures?
No
Yes
Bleeding Problems?
No
Yes
Gout or Arthritis?
No
Yes
Children
Glaucoma?
No
Yes
Asthma or Hives?
No
Yes
Other:
IMMUNIZATIONS
Have you had the basic immunization series of:
Tetanus and Diphtheria?
No
Yes
Tetanus Booster in the past 10 years?
No
Yes
Polio?
No
Yes
Measles, Mumps and Rubella (MMR)
No
Yes
Hepatitis A?
No
Yes
Pneumonia Vaccine?
No
Yes
Hepatitis B?
No
Yes
SOCIAL HISTORY
Are you:(Check One)
Single
Married
Separated
Divorced
Widowed
Living with partner
Other
Are you living with you husband, wife or partner?
No
Yes
Is your sex life satisfactory?
No
Yes
Do you have dependents at home?
No
Yes
Do you drink alcoholic beverages?
No
Yes
How much per day/week?
Has anyone ever told you that you drink too much?
No
Yes
Do you now smoke?
No
Yes
How many?
How long?
Did you ever smoke?
No
Yes
When did you stop?
Do you drink coffee, cola or tea?
No
Yes
How many Cups?
Do you exercise?
No
Yes
How much?
Have you used illicit drugs?
No
Yes
Which drugs and when?
Have you ever been tested for HIV?
No
Yes
Would you like to be?
No
Yes
What is/was your occupation?
Highest education obtained:
Describe job stress:(Check One)
High
Medium
Low
Do you wear seat belts?
No
Yes
SCREENING TEST:
(if applicable)
Have you ever had a:
Mammogram?
No
Yes
When was it last done?
Bone Density Test?
No
Yes
When was it last done?
Chest X-Ray?
No
Yes
When was it last done?
EKG?
No
Yes
When was it last done?
Exercise Stress Test?
No
Yes
When was it last done?
Flexible Sigmoidoscopy?
(Colonoscopy?)
No
Yes
When was it last done?
Other:
When was it last done?
SYSTEMS REVIEW:
Do you have any of the following:
GENERAL:
NECK:
Unexplained weight loss?
No
Yes
Stiffness?
No
Yes
Chronic Fevers?
No
Yes
Neck Injury?
No
Yes
Loss of appetite?
No
Yes
Enlarged neck glands?
No
Yes
SKIN:
RESPIRATORY:
Skin Disease?
No
Yes
Coughing/Spitting Blood?
No
Yes
Jaundice?
No
Yes
Chronic cough?
No
Yes
Hives or Eczema?
No
Yes
Asthma or wheezing?
No
Yes
Frequent infections or boils?
No
Yes
Shortness of breath?
No
Yes
Abnormal moles?
No
Yes
Difficulty walking 2 blocks?
No
Yes
Night sweats?
No
Yes
Skin tested for tuberculosis?
No
Yes
HEAD-EYES-EARS-NOSE-THROAT:
CARDIOVASCULAR:
Eye disease?
No
Yes
Chest pain or angina?
No
Yes
Do you wear glasses?
No
Yes
Heart Trouble?
No
Yes
Blurred vision?
No
Yes
Heart attack or Heart Disease?
No
Yes
Glaucoma?
No
Yes
Shortness of breath when laying down?
No
Yes
Frequent headaches?
No
Yes
Wake up short of breath?
No
Yes
Itchy eyes, runny nose, sneezing?
No
Yes
Heart murmurs?
No
Yes
Frequent nosebleeds?
No
Yes
Rapid or skipped heartbeats?
No
Yes
Chronic ringing in ear?
No
Yes
Swelling of hands, feet, or ankles?
No
Yes
Sinus trouble?
No
Yes
Hearing loss or disease?
No
Yes
Dizziness or fainting spells?
No
Yes
GASTROINTESTINAL:
MUSCULOSKELETAL:
Stomach or duodenal ulcer?
No
Yes
Significant arthritis?
No
Yes
Heartburn or Indigestion?
No
Yes
Weakness in leg or arm?
No
Yes
Sour taste in throat or mouth?
No
Yes
Difficulty walking?
No
Yes
Use antacids or Tums often?
No
Yes
Pain in calves or buttock on walking?
No
Yes
Intolerance to spicy foods, coffee or alcohol?
No
Yes
Painful varicose veins?
No
Yes
Vomiting up blood?
No
Yes
Food/liquid get stuck in your throat?
No
Yes
NEUROLOGICAL:
Gallbladder trouble?
No
Yes
Stroke?
No
Yes
Intolerance to greasy food?
No
Yes
Seizures?
No
Yes
Liver trouble?
No
Yes
Paralysis?
No
Yes
Cramping, abdominal pain?
No
Yes
Numbing or tingling?
No
Yes
Chronic Constipation?
No
Yes
Loss of consciousness?
No
Yes
Frequent diarrhea?
No
Yes
Use laxatives often?
No
Yes
EMOTIONAL:
Recent change in bowel habits?
No
Yes
Do you sleep well?
No
Yes
Bloody or black stools?
No
Yes
Are you usually tired?
No
Yes
Hemorrhoids or piles?
No
Yes
Are you often depressed?
No
Yes
Are you often anxious?
No
Yes
GENITOURINARY:
Do you feel helpless or hopeless?
No
Yes
Leak urine when cough or sneeze?
No
Yes
Do you wish you were dead?
No
Yes
Frequent bladder/kidney infections?
No
Yes
Do you worry often?
No
Yes
Burning or painful urination?
No
Yes
Do you have interests in friends or fun?
No
Yes
Nighttime urination?
No
Yes
Have you ever been advised to see a psychiatrist?
No
Yes
Feeling that you must urinate immediately?
No
Yes
Bloody, pink or brown urine?
No
Yes
HEMATOLOGICAL:
Kidney stones?
No
Yes
Anemia?
No
Yes
Unexplained bruising?
No
Yes
FOR MEN ONLY:
Excessive bleeding?
No
Yes
Difficulty starting urination?
No
Yes
Decrease in strength of
urine stream?
No
Yes
ENDOCRINE (hormone):
Discharge from penis?
No
Yes
Hormone therapy?
No
Yes
Difficulty starting or
maintaining erection?
No
Yes
Thyroid disease?
No
Yes
Prostate problems?
No
Yes
Intolerance to mildly warm or mildy cold temperatures?
No
Yes
Change in texture of hair or skin?
No
Yes
FOR WOMEN ONLY:
Change in voice?
No
Yes
Age when period started:
(Years old)
Crave large amounts of fluids?
No
Yes
Frequency of periods:
(every __ days)
Significant change in shoe size?
No
Yes
Length of each period:
Severe fatigue?
No
Yes
Number of pregnancies:
Number of deliveries:
Date of last Pap Smear
Abnormal discharge or odor?
No
Yes
Height
ft
in
Weight
Extremely painful periods?
No
Yes
Painful intercourse?
No
Yes
Breast lumps or pain?
No
Yes
I affirm that the information provided above is true and
understand that checking this box
is the equivalent of my signature.
Name:
Date:
