Patient Questionnaire

Name:

Date of Birth:

Date:

1. Age (if alive)

Mother:

Father:

Siblings:

Children

2. Health(good/bad)

Mother:

Father:

Siblings:

Children:

3. Cancer

Mother:

Father:

Siblings:

Children:

4. Tuberculosis

Mother:

Father:

Siblings:

Children:

5. Diabetes

Mother:

Father:

Siblings:

Children:

5. Heart Issues

Mother:

Father:

Siblings:

Children:

6. Hypertension

Mother:

Father:

Siblings:

Children:

7. Stroke

Mother:

Father:

Siblings:

Children:

8. Epilepsy

Mother:

Father:

Siblings:

Children:

10. Nervous Breakdown

Mother:

Father:

Siblings:

Children:

11. Asthma, hives, hayfever

Mother:

Father:

Siblings:

Children:

12. Blood disease

Mother:

Father:

Siblings:

Children:

13. Age (at death)

Mother:

Father:

Siblings:

Children:

14. Cause of death

Mother:

Father:

Siblings:

Children:

Personal History

Please select the symptoms that apply to why you are being seen by us today:

If Cancer is selected, please specify what type:

If Diabetes is selected, please specify what type:

Please list any other medical conditions:

Please list all Allergies (i.e. medications, foods, household products, etc)

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Please list ALL surgeries AND hospitalizations:

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Please list ALL diagnostic/radiological tests and WHY they were done:

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Do you exercise adequately?

No Yes

If yes, how?

Do you sleep well?

No Yes

How many hours per night do you sleep?

Do you have regular bowel movements?

Is sex satisfactory?

No Yes

Do you like your work?

No Yes

Do you work Indoors or outdoors?

How many hours a day do you watch TV?

How many hours a day do you read?

How many weeks in a year do you take vacation?

Have you ever been treated for alcoholism?

No Yes

Have you ever been treated for drug abuse?

No Yes

Please list ALL medications/supplements you take:

Add new row

Do you often feel any of the below emotions?

Depressed

Anxious

Irritable

Jumpy

Jittery

Trouble concentrating

WOMEN ONLY

Age at onset of menstrual cycle:

Usual duration of menstrual cycle:

Date of last period:

Are you regular?

No Yes

Are you:

Heavy Medium Light

Do you have Tension or Depression before your cycle?

Do you have Cramps or Pain associated with your cycle?

Do you have hot flashes?

No Yes

Children born alive:

Still born:

Miscarriages:

Children born from cesarean:

Premature:

Vaginal:

Were there any pregnancy complications?

Completed by:

Patient Other

If Other is selected, please specify:

Relationship:

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