Home / About / Patient Health HistoryPatient Health History Health History Form Please fill out the following form about your and your family's medical history. Health History Questionnaire Name * Name First First Last Last Date Gender * Male Female Birth Date * Personal Health History Please check all that apply Childhood Illnesses Measles Mumps Rubella Chickenpox Rheumatic Fever Polio Immunizations & Dates Tetanus Tetanus Tetanus Date Pneumonia Pneumonia Pneumonia Date Hepatitis B Hepatitis B Hepatitis B Date Chickenpox Chickenpox Chickenpox Date Influenza Influenza Influenza Date Shingles Shingles Shingles Date MMR (Measles, Mumps and Rubella) MMR (Measles, Mumps and Rubella) MMR Date Patient's Medication Including prescriptions, herbals, and over the counter drugs such as VITAMINS & INHALERS Name of Medication Strength Frequency Taken Add Remove Current Pharmacy Provider * City of Pharmacy * List of Patient's Allergies List all allergies to medications, foods, contrast, and dyes. List allergy Add Remove Medical Problems Mark ALL medical problems that other Doctors or care providers have diagnosed you with. Medical Issues Allergies Anemia Anxiety Alcoholism Arthritis Asthma Blood Transfusion Bleeding Problems Cancer Cataracts CHF - Heart Failure Breast Lumps Clotting Disorder COPD Depression Cirrhosis (Liver) Diabetes Emphysema GERD/Reflux Fibromyalgia Glaucoma Heart Murmur HIV/AIDS Sexually Transmitted Infection High Blood Pressure Kidney Disease Meningitis Gallbladder Disease Heart Attack Nerve/Muscle Disease Osteoporosis Hepatitis Seizures Sickle Cell Anemia Stroke Incontinence Substance Abuse Thyroid Disease Tuberculosis Irregular Heart Rate Kidney Failure Mental Illness Migraines/Headaches Skin Problems Ulcers Fracture/Joint Surgery Surgeries (tonsils, appendix, C-section, joints, tubal ligation, fracture repair) Year Type of Surgery Reason Hospital, City & State Add Remove Have you ever had a blood transfusion (received blood)? Yes No Health Habits and Safety Please check all that apply Alcohol Do you drink alcohol? Yes No If yes, what kind? On average, how many drinks per week? Are you concerned about the amount you drink? Yes No Have you considered stopping? Yes No Have you experienced blackouts? Yes No Are you prone to binge drinking? Yes No Do you drive after drinking? Yes No Tobacco Do you use tobacco? Yes No Cigarettes per day? Chew cans per day? Cigars per day? How many years? Year you quit? Drugs Do you currently use recreational or street drugs? (Marijuana, heroin, meth, etc.) Yes No Have you ever given yourself street drugs using a needle? Yes No Sex Are you sexually active? Yes No If yes, are you trying for pregnancy? Yes No If not trying for pregnancy, list contraceptives/barrier methods you use: Any discomfort during intercourse? Yes No Unprotected sex & IV drug use are risk factors for HIV/AIDS. Would you like to discuss your risk of these illnesses with your provider? Yes No Personal Safety Do you live alone? Yes No Do you fall frequently? Yes No Do you have vision loss? Yes No Do you have hearing loss? Yes No Do you have an Advanced Directive or Living Will? Yes No Physical/mental abuse often takes the form of verbal threats and/or actual physical or sexual abuse. Would you like to discuss this issue with your provider? Yes No Are you being abused? Yes No Are you homeless? Yes No Are you on food stamps? Yes No Family Health History Include the age at death if deceased Father Alive Deceased Father - Significant Health Problems Mother Alive Deceased Mother - Significant Health Problems Maternal Grandmother Alive Deceased Maternal Grandmother - Significant Health Problems Maternal Grandfather Alive Deceased Maternal Grandfather - Significant Health Problems Paternal Grandmother Alive Deceased Paternal Grandmother - Significant Health Problems Paternal Grandfather Alive Deceased Paternal Grandfather - Significant Health Problems Siblings Please indicate Male or Female Name Sibling Alive Deceased Gender Male Female Significant Health Problems Add Remove Children Please indicate Male or Female Name Children Alive Deceased Gender Male Female Significant Health Problems Add Remove Family History Please check if family member had the listed problem. Alcohol/drug abuse Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Allergies Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Arthritis Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Asthma Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Bleeding/blood problems Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Cancer Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) COPD Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Depression Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Diabetes Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Gastrointestinal problems Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Genetic diseases/birth defects Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Genitourinary Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Headaches Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Heart problems Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) High Cholesterol Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Hypertension Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Kidney Disease Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Mental Illness Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Musculoskeletal disorders Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Nervous system disorder Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Obesity Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Osteoporosis Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Sickle cell anemia Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Stroke Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Thyroid Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Tuberculosis Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Vision Problems Mother Father Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Brother 3 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Male 1) Children (Male 2) Children (Female 1) Children (Female 2) Activities of Daily Living and Concerns Please check all that apply and add comments if needed Military? If yes, what branch? Yes No Comments Any caffeine concerns? Yes No Comments Any hobby hazards (home)? Yes No Comments Any stress concerns? Yes No Comments Are you currently on a special diet? Yes No Comments Any exercise concerns? Yes No Comments Do you wear a seatbelt? Yes No Comments Have you ever had a blood transfusion? Yes No Comments Any occupational (work) hazards? Yes No Comments Any sleep concerns? Yes No Comments Any weight concerns? Yes No Comments Any back care concerns? Yes No Comments If you bike, do you wear a helmet? Yes No Comments Do you perform any self-exams? Yes No Comments Symptoms Please CHECK ALL items which apply to your health during the PAST 6 MONTHS. If none, check here If none, check here Head, ears, eyes, nose, mouth, and throat Blurred vision Ringing in ears Hearing difficulties Mouth sores Loss or change in taste Difficulty chewing/swallowing Headache Dizziness Fever Voice change or persistent hoarseness Gastrointestinal tract Loss of appetite Nausea Heartburn Indigestion or belching Pain/discomfort in upper abdomen or stomach Other abdominal pain Constipation Diarrhea Hemorrhoids/rectal bleeding Black tarry stools Musculoskeletal Joint pain Joint swelling Lower back pain General back pain Neck pain Muscle pain Muscle weakness Morning muscle/joint stiffness Decreased muscle control Chest, lungs, and heart Chest pain Shortness of breath Wheezing (asthma) Pneumonia Gastrointestinal tract Depression or anxiety Insomnia Tiredness (Fatigue) Trouble thinking or remembering Skin Easy bruising Hives or welts Itching Rash Women Only Age of onset menstruation Date of last menstruation Number of pregnancies Number of live births Date of last mammogram Date of last pap and rectal exam reCAPTCHA If you are human, leave this field blank. 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