Health Questionaire
Name:
Occupation:
Past Medical and Family History
Date of Birth:
Revised 2/3/2015
Self
Family
Self
(Specific Family Member)
Recent Weight Loss
Migraine Headaches
Epilepsy/Convulsions
Eye disease
Hearing disorder
Recurrent nose bleeds
Recurrent sinus/throat infections
Angina - Chest pain
Heart Attack
High Blood Pressure
Stroke
High Cholesterol
Heart valve disorder
Lung disease
Stomach Ulcer
Bowel Problems
Liver disease/Hepatitis
Date:
Family
(Specific Family Member)
Kidney/bladder problems
Neurological problems
Arthritis
Osteoporosis
Cancer-Type( cancer type/family
member)
Bleeding disorder
Blood transfusion(s)
Anemia
Diabetes
Thyroid disorder
Alcohol/Drug abuse
Mental illness
Depression/Anxiety
Psoriasis/Eczema
Hair Loss
Accident-Major
Hospitalizations/Surgeries
Year
Illness/Operation
Year
Illness/Operation
List All Current Medications You Take
Do you Now OR Have you Ever Consumed
Medication
Dose
Frequency Cigarettes Y
N Daily Amt________# Yrs______
Alcohol
Y
N Drinks/WK_________________
Caffeine
Y
N Cups/Day__________________
Drugs
Y
N Type_______________________
The Last time (Year) you had;
Flu Vaccine (type?)______________TB test________
Pneumonia 23 vaccine________Prevnar 13 vaccine________
T.B. Test_____ Hepatitis B vaccine_____,_____,_____
Td (tetanus) shot__________Tdap_____________
Stool blood test___________ PSA_______________
Cholesterol Test_________ Colonoscopy_________
Dental Exam____________ Eye exam____________
Breast Exam _______
_____ Pap
_____ Normal
_____ ABN
_____ Bone Density _____ Normal
_____ ABN
_____ Mammogram _____ Normal
_____ ABN
Drug Allergies
Drug
Reaction
For Women Only
Date of Last Cycle:
Birth Control: Y N
Type:______________
How Many:
Pregnancies________
Births_____________
Abortions__________
Miscarriages________
Is your Child around
Secondhand Smoke?
Y
N