Health History Questionnaire

Original Date:

Date Revised:

Health History Questionnaire

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Last Name:

First Name:

Middle Initial:

What sex is listed on your original birth certificate?

What is your gender identity?

Date of Birth:

Marital Status:

Single Partnered Married Separated Divorced Widowed

Previous or referring Doctor:

Date of last physical exam:

Personal Health History

Childhood illness:

Measles Mumps Rubella Chickenpox Rheumatic Fever Polio

Immunizations and dates:

Tetanus

Date:

Hepatitis

Date:

Influenza:

Date:

Chickenpox:

Date:

Influenza:

Date:

MMR (Measles, Mumps, Rubella)

Date:

List any medical problems that other doctors have diagnosed:

Surgeries

Year:

Reason:

Hospital:

Add Information

Other Hospistalizations

Year:

Reason:

Hospital:

Add Information

Have you ever had a blood transfusion?

Yes No

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Name the Drug:

Strength:

Frequency Taken:

Add Information

Allergies to medications

Name the Drug:

Reaction you had:

Add Information

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:

Are you dieting?

Yes No

If yes, are you on a physician prescribed medical diet?

Yes No

No. of meals you eat in an average day?

Rank salt intake:

Hi Med Low

Rank fat intake:

Hi Med Low

Caffeine:

None Coffee Tea Cola

No. of Cups/Cans per day?

Alcohol

Do you drink alcohol?

Yes No

If yes, what kind?

How many drinks per week?

Are you concerned about the amount you drink?

Yes No

Have you considered stopping?

Yes No

Have you ever 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

Packs/day:

Chew

How much per day:

Pipe

How much per day:

Cigars

How many per day:

How many years have you been using tobacco?

If you quit tobacco, what year?

Drugs

Do you currently use recreational or street drugs?

Yes No

Have you ever given yourself street drugs with a needle?

Yes No

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

Do you live alone?

Yes No

Do you have frequent falls?

Yes No

Do you have vision or hearing loss?

Yes No

Do you have an Advance Directive and/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's Age:

Father's Significant Health Problems:

Mother's Age:

Mother's Significant Health Problems:

Sibling:

Male Female

Sibling's Age:

Sibling's Significant Health Problems:

Add sibling

Child:

Male Female

Child's Age:

Child's Significant Health Problems:

Add child

Grandparents (Maternal)

Grandmother's Age:

Grandmother's Significant Health Problems:

Grandfather's Age:

Grandfather's Significant Health Problems:

Grandparents (Paternal)

Grandmother's Age:

Grandmother's Significant Health Problems:

Grandfather's Age:

Grandfather's Significant Health Problems:

Mental Health

Is stress a major problem for you?

Yes No

Do you feel depressed?

Yes No

Do you panic when stressed?

Yes No

Do you have problems with eating or your appetite?

Yes No

Do you cry frequently?

Yes No

Have you ever attempted suicide?

Yes No

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

Age at onset of menstruation:

Date of last menstruation:

Period every how many days:

Heavy periods, irregularity, spotting, pain, or discharge?

Yes No

Number of pregnancies:

Number of live births:

Are you pregnant or breastfeeding?

Yes No

Have you had a D&C, hysterectomy, or Cesarean?

Yes No

Any urinary tract, bladder, or kidney infections within the last year?

Yes No

Any blood in your urine?

Yes No

Any problems with control of urination?

Yes No

Any hot flashes or sweating at night?

Yes No

Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?

Yes No

Experienced any recent breast tenderness, lumps, or nipple discharge?

Yes No

Date of last pap and rectal exam?

Men Only

Do you usually get up to urinate during the night?

Yes No

If yes, # of times:

Do you feel pain or burning with urination?

Yes No

Any blood in your urine?

Yes No

Do you feel burning discharge from penis?

Yes No

Has the force of your urination decreased?

Yes No

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

Any difficulty with erection or ejaculation?

Yes No

Any testicle pain or swelling?

Yes No

Date of last prostate and rectal exam?

Health History Questionnaire