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Original Date:

Dates Revised:

enter text.

HEALTH HISTORY QUESTIONNAIRE

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

Initials:

Race/Ethnicity:

☐M ☒

Age

Occupation: Student

Marital status:

☒ Single ☐ Partnered ☐ Married ☐ Separated ☐ Divorced ☐ Widowed

Reason for visit: Physical assessment

Perception of health:enter text.

Date of last physical exam:

8/22/2018

Source of information: enter text.

Reason for seeking care: Physical Assessment

Present health or history of present illness:

enter text.

PERSONAL HEALTH HISTORY/Past health

Childhood illness:

◻ Measles ◻ Mumps ◻ Rubella ◻ Chickenpox ◻ Rheumatic Fever ◻ Polio

Immunizations and dates:

☒Tetanus

Up to date

☒Pneumonia

Up to date

☒Hepatitis

Up to date

☒Chickenpox

Up to date

☒Influenza

Up to date

☒MMR Measles, Mumps, Rubella

Up to date

List any medical problems that other doctors have diagnosed

N/A

Surgeries

Year

Reason

Hospital

N/A

enter text.

Other hospitalizations

Year

Reason

Hospital

N/A

enter text.

Have you ever had a blood transfusion?

☐

Yes

☒

Please turn to next page

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

Name the Drug

Strength

Frequency Taken and Reason

Claritin

enter text.

1 or 3 times per week

enter text.

Allergies to medications, latex, food, iodine/betadine

Name the Drug

Reaction You Had

N/A

enter text.

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

☒

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

☐

Yes

☐

# of meals you eat in an average day? Click or tap here to enter text.

Rank salt intake

☐Hi

☐Med

enter text.Low

Rank fat intake

☐Hi

☐Med

enter text.Low

Caffeine

◻ None

☒Coffee

☐Tea

Coke Cola

# of cups/cans per day? 1 cup/day

Alcohol

Do you drink alcohol?

☒

Yes

☐

If yes, what kind? Beer

How many drinks per week? 1 per week

Are you concerned about the amount you drink?

☐

Yes

☒

Have you considered stopping?

☐

Yes

☒

Have you ever experienced blackouts?

☐

Yes

☒

Are you prone to “binge” drinking?

☐

Yes

☒

Do you drive after drinking?

☐

Yes

☒

Tobacco

Do you use tobacco?

☐

Yes

☒

☐Cigarettes – pks./day enter text.o

☐Chew - #/day enter text.

☐Pipe - #/day enter text.

☐Cigars - #/day enter text.

☐ # of years enter text.

☐Or year quit enter text.

Drugs

Do you currently use recreational or street drugs?

☐

Yes

☒

Have you ever given yourself street drugs with a needle?

☐

Yes

☒

Sex

Are you sexually active?

☒

Yes

☐

If yes, are you trying for a pregnancy?

☐

Yes

☒

If not trying for a pregnancy list contraceptive or barrier method used: birth control

Any discomfort with intercourse?

☐

Yes

☒

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

☒

Personal Safety

Do you live alone?

☐

Yes

☒

Do you have frequent falls?

☐

Yes

☒

Do you have vision or hearing loss?

☒

Yes

☐

Do you have an Advance Directive and/or Living Will?

☐

Yes

☒

Would you like information on the preparation of these?

☐

Yes

☒

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

☒

FAMILY HEALTH HISTORY

Age

Significant Health Problems

Age

Significant Health Problems

Father

Arthritis

Children

☐M ☐ F

N/A

Mother

N/A

☐M ☐ F

N/A

Sibling

☒M 23 years old ☐ F

N/A

☐M ☐ F

N/A

☐M ☐ F

N/A

☐M ☐ F

N/A

☐M ☐ F

N/A

Grandmother

Maternal

passed from Stomach cancer in 1978

☐M ☐ F

N/A

Grandfather

Maternal

enter text.

unknown

☐ M ☐ F

N/A

Grandmother

Paternal

enter text.

passed from aneurysm in 1980

☐M ☐ F

N/A

Grandfather

Paternal

enter text.

passed from lymphoma and lung cancer in 1984

MENTAL HEALTH

Comments

Is stress a major problem for you?

☐

Yes

☐

Do you feel depressed?

☐

Yes

☐

Do you panic when stressed?

☐

Yes

☐

Do you have problems with eating or your appetite?

☐

Yes

☐

Do you cry frequently?

☐

Yes

☐

Have you ever attempted suicide?

☐

Yes

☐

Have you ever seriously thought about hurting yourself?

☐

Yes

☐

Do you have trouble sleeping?

☐

Yes

☐

Have you ever been to a counselor?

☐

Yes

☐

WOMEN ONLY

Age at onset of menstruation: 12.

Date of last menstruation: May 15, 2019

Period every 28 days

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

☐

Yes

☐

Number of pregnancies enter text. Number of live births enter text.

Are you pregnant or breastfeeding?

☐

Yes

☐

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

☐

Yes

☐

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

☐

Yes

☐

Any blood in your urine?

☐

Yes

☐

Any problems with control of urination?

☐

Yes

☐

Any hot flashes or sweating at night?

☐

Yes

☐

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

☐

Yes

☐

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

☐

Yes

☐

Date of last pap and rectal exam? 2017.

MEN ONLY

Do you usually get up to urinate during the night?

☐

Yes

☐

If yes, # of times enter text.

Do you feel pain or burning with urination?

☐

Yes

☐

Any blood in your urine?

☐

Yes

☐

Do you feel burning discharge from penis?

☐

Yes

☐

Has the force of your urination decreased?

☐

Yes

☐

Have you had any kidney, bladder, or prostate infections within the last 12 months?

☐

Yes

☐

Do you have any problems emptying your bladder completely?

☐

Yes

☐

Any difficulty with erection or ejaculation?

☐

Yes

☐

Any testicle pain or swelling?

☐

Yes

☐

Date of last prostate and rectal exam? enter text.

review of systems

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.

☐

Skin/Hair/Nails enter text.

☐

Respiratory enter text.

☐

Neurologic enter text.

☐

Head/Neck enter text.

☐

Cardiovascular enter text.

☐

Recent changes in Weight enter text.

☐

Eyes Bilateral Myopia and Astigmstism

☐

Peripheral Vascular enter text.

☐

Recent changes in Energy level enter text.

☐

Ears enter text.

☐

Gastrointestinal enter text.

☐

Sleep/rest pattern enter text.

☐

Nose enter text.

☐

Urinary UTI

☐

Other pain/discomfort: enter text.

☐

Mouth/Throat enter text.

☐

Musculoskeletal enter text.