Patient’s History and Health Questionnaire

July 18, 2017

Use this form to collect new patient health history, or to collect updated health history on established patients that have not been seen by you for several years.

PATIENT’S HISTORY AND HEALTH QUESTIONNAIRE

 

NAME:                                                  D.O.B.                         DATE                                           

PLEASE LIST ANY CONDITION OR DISEASE WHICH YOU WISH TO HAVE CHECKED AT THIS EXAMINATION:

PAST MEDICAL HISTORY

Date            (Age)        Illness, Injury, Hospitalization or Surgery

________(___ )                                                                                                                                   ________( ___)                                                                                                                                   ________( ___)                                                                                                                                   ________( ___)                                                                                                                                   ________(___ )                                                                ____                            ________( ___)                                                                                                                                    

CIRCLE ANY OF THE FOLLOWING CONDITIONS WHICH YOU NOW HAVE OR HAVE HAD IN THE PAST

Skin Trouble Tuberculosis Jaundice Prostate Trouble Diabetes
Cataracts Hardening of Arteries Gallstones Syphilis Mononucleosis
Tonsillitis Heart Attack Liver Condition Gonorrhea Polio
Sinusitis Heart Murmur Hepatitis Hernia Diphtheria
Hay Fever High Blood Pressure Ulcers Leukemia Malaria
Goiter High Cholesterol Nervous Stomach/Colon Cancer or Tumor Mumps
Thyroid Disorder High Triglycerides Diverticulitis Breast Problems Measles
Asthma Stroke Hemorrhoids Nervous Breakdown Chicken Pox
Bronchitis Paralysis Kidney Trouble Anemia Rheumatic Fever
Emphysema Unconsciousness Kidney Stones Phlebitis Arthritis
Pneumonia Fits/Convulsions Bladder Trouble Varicose Veins Gout

LIST ALL MEDICATIONS YOU TAKE REGULARLY OR OCCASIONALLY:          MEDICATION ALLERGIES

SMOKING:

CIGARETTES

CIGARS

PIPE

Age Began: _____
Packs per day: _____
Age Quit: _____

ALCOHOL

None: _____

Occasional Social: _____

Daily: _____

Beers per day: _____

Drinks per day: _____

(No.) Ages (Living/Dead)    Medical Problems/Cause of death

Father:                                                                                                                                                                           Mother:                                                                                                                                                                         Brothers: (   )                                                                                                                                                           Sisters:   (   )                                                                                                                                                          Children: (   )                                                                                                                                                          

PLEASE CIRCLE ALL CONDITIONS WHICH BLOOD RELATED FAMILY MEMBERS HAVE OR HAVE HAD:

Tuberculosis Stroke Goiter Nervous/Emotional Disorder
Hypertension Gall Stones Thyroid Alcoholism
Heart Attacks Kidney Disease Arthritis/Gout Epilepsy
Heart Disease Anemia Migraine Headaches Cancer
Diabetes Bleeding Disorder Nerve/Muscle Disorder Leukemia

 

 

REVIEW OF SYSTEMS: Circle YES for any of the following complaints or conditions you have had in the last 3 months. (If you do not understand, place an asterisk * beside “Yes”.)

 

 

GENERAL HEART & LUNGS
Weight gain or loss (over 5 lbs) . . . . . . . . . . . Yes Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Coughing up sputum or blood . . . . . . . . . . . . . Yes
Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Shortness of breath . . . . . . . . . . . . . . . . . . . . . . Yes
Fever/Chills . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Wheezing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Night sweats . . . . . . . . . . . . . . . . . . . . . . . . . Yes Sleep sitting up/more than two pillows . . . . . . Yes
Tend to be hot/cold most of the time . . . . . . . Yes Awaken from sleep short of breath . . . . . . . . . Yes
SKIN Pain or tightness in chest:
Change in skin . . . . . . . . . . . . . . . . . . . . . . . . Yes when you exercise . . . . . . . . . . . . . . . . . . Yes
Rash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes when you are nervous . . . . . . . . . . . . . . . Yes
Itching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes when you have eaten a big meal . . . . . . . Yes
Change in hair . . . . . . . . . . . . . . . . . . . . . . . . Yes Heart murmur . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Mole or sore which does not heal . . . . . . . . . Yes Swelling of feet/ankles . . . . . . . . . . . . . . . . . . Yes
HEAD Pounding/skipping of heart . . . . . . . . . . . . . . . Yes
Frequent headaches . . . . . . . . . . . . . . . . . . . . Yes Heart starts racing suddenly . . . . . . . . . . . . . . Yes
Migraine headaches . . . . . . . . . . . . . . . . . . . . Yes Leg cramps while walking . . . . . . . . . . . . . . . Yes
EYES High blood pressure . . . . . . . . . . . . . . . . . . . . Yes
Wears glasses . . . . . . . . . . . . . . . . . . . . . . . . . Yes Fainting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Blurring of vision . . . . . . . . . . . . . . . . . . . . . Yes GASTROINTESTINAL
Double vision . . . . . . . . . . . . . . . . . . . . . . . . Yes Loss of appetite . . . . . . . . . . . . . . . . . . . . . . . . Yes
Blind spots . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Pain/difficulty swallowing . . . . . . . . . . . . . . . . Yes
Light hurts eyes . . . . . . . . . . . . . . . . . . . . . . Yes Heartburn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Eye pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Belching, bloating, indigestion . . . . . . . . . . . . Yes
EARS Nausea/vomiting . . . . . . . . . . . . . . . . . . . . . . . Yes
Hearing loss . . . . . . . . . . . . . . . . . . . . . . . . . Yes Vomiting blood/coffee ground material . . . . . Yes
Noise in the ears . . . . . . . . . . . . . . . . . . . . . . Yes Burning or hunger pains relieved by eating
Dizziness or vertigo . . . . . . . . . . . . . . . . . . . Yes or antacids . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Earache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Intolerance of fatty foods . . . . . . . . . . . . . . . . . Yes
NOSE Yellow skin or eyes (jaundice) . . . . . . . . . . . . . Yes
Frequent nose bleeds . . . . . . . . . . . . . . . . . . Yes Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Stuffy of runny nose . . . . . . . . . . . . . . . . . . Yes Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Postnasal drip . . . . . . . . . . . . . . . . . . . . . . . Yes Cramps in stomach or lower down . . . . . . . . . Yes
MOUTH & THROAT Fresh or bright blood in stool
Dentures . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes (bowel movement) . . . . . . . . . . . . . . . . . . . Yes
Sore in mouth/on tongue . . . . . . . . . . . . . . Yes Black/tarry stools (bowel movement) . . . . . . . . Yes
Sore throat/tonsillitis . . . . . . . . . . . . . . . . . Yes Mucus (slime/phlegm in stool) . . . . . . . . . . . . . Yes
Sore or bleeding gums . . . . . . . . . . . . . . . . Yes Pain in rectum . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Difficulty speaking . . . . . . . . . . . . . . . . . . . Yes FEMALE GENITALIA & PREGNANCY
Hoarseness or change in voice . . . . . . . . . . Yes Number of pregnancies                           
NECK Number of deliveries                              
Pain or stiffness in neck . . . . . . . . . . . . . . . Yes Vaginal deliveries                                  
Swelling of glands in neck . . . . . . . . . . . . . Yes Cesarean deliveries                                
Goiter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Number of stillbirths                              
Swelling in neck . . . . . . . . . . . . . . . . . . . . . Yes Number of miscarriages                          

 

 

 

MENSES (monthly periods)

The last menstrual period began                                                                 Now occurs about every                              days

Normal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

 

 

Yes

NEUROLOGICAL

Seizures or epilepsy . . . . . . . . . . . . . . . . . . . . Paralysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Muscle weakness . . . . . . . . . . . . . . . . . . . . . .

 

Yes

Yes Yes

Flooding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Loss or change in sensation . . . . . . . . . . . . . . Yes
Irregular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Numbness or tingling sensations . . . . . . . . . . Yes
Painful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Tremor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Spotting between periods . . . . . . . . . . . . . . . Yes Difficulty walking . . . . . . . . . . . . . . . . . . . . . Yes
Age when “Change of Life” started . . . . . . . Yes Loss of coordination . . . . . . . . . . . . . . . . . . . . Yes
Hot flashes . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Memory change . . . . . . . . . . . . . . . . . . . . . . . Yes
Vaginal discharge . . . . . . . . . . . . . . . . . . . . . Yes MOOD
Pain with sexual intercourse . . . . . . . . . . . . Yes Nervous with strangers . . . . . . . . . . . . . . . . . Yes
Hysterectomy Date                         . . . . . . . . Yes Difficulty making decisions . . . . . . . . . . . . . Yes
Cause                                                   Lack of concentration or memory . . . . . . . . . Yes
Birth control pills . . . . . . . . . . . . . . . . . . . . . Yes Lonely or depressed . . . . . . . . . . . . . . . . . . . . Yes
Lumps or masses in breasts . . . . . . . . . . . . . Yes Cry often . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Pain in breasts . . . . . . . . . . . . . . . . . . . . . . . Yes Hopeless outlook . . . . . . . . . . . . . . . . . . . . . . Yes
Discharge from breasts . . . . . . . . . . . . . . . . Yes Difficulty relaxing . . . . . . . . . . . . . . . . . . . . . Yes
Date of last pelvic exam                              Worry a lot . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Date of last PAP smear                               Sexual difficulties . . . . . . . . . . . . . . . . . . . . . Yes
Name of OB/Gyn Doctor who sees you: Considered suicide . . . . . . . . . . . . . . . . . . . . . . Yes
MALE GENITAL IMMUNIZATIONS
Burning/discharge from penis . . . . . . . . . . . Yes (Please enter date of latest immunization)
Sores/ulcers on penis . . . . . . . . . . . . . . . . . . Yes
Sores/swelling in groin . . . . . . . . . . . . . . . . Yes Influenza (Flu)                                                       
Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Pain/swelling in testes . . . . . . . . . . . . . . . . . Yes Tetanus/Diptheria (Td)                                           
Infertility problem . . . . . . . . . . . . . . . . . . . . Yes
Difficulty in gaining an erection . . . . . . . . . Yes Tetanus/Diptheria/Pertussis (TDAP)                         
Inability to have orgasm (reach climax) . . . Yes
Trouble starting urination . . . . . . . . . . . . . . Yes Pneumovax                                                          
Urine stream has become weak . . . . . . . . . . Yes
UROLOGIC Zostavax (Shingles)                                                
Pain or burning with urination
(passing water) . . . . . . . . . . . . . . . . . . . Yes Human Papillomavirus (HPV)                           
Blood in urine . . . . . . . . . . . . . . . . . . . . . . . . Yes
Sugar in urine . . . . . . . . . . . . . . . . . . . . . . . . Yes Measles/Mumps/Rubella (MMR)                           
Frequent urination . . . . . . . . . . . . . . . . . . . . . Yes
Pain over bladder or lower down . . . . . . . . . . Yes Meningococcal                           
Hard to empty bladder completely . . . . . . . . . Yes
Lose control of passing urine . . . . . . . . . . . . . Yes Hepatitis A                           
Getting up at night to urinate . . . . . . . . . . . . . Yes
Number of times                             Hepatitis B                           

 

MUSCULOSKELETAL

Back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . .       Yes

Pain in joints . . . . . . . . . . . . . . . . . . . . . . . . .   Yes Pain or soreness in muscles . . . . . . . . . . . . . .       Yes

Stiffness in joints or muscles . . . . . . . . . . . . .   Yes BLOOD

Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       Yes

Bruises easily . . . . . . . . . . . . . . . . . . . . . . . . .       Yes

Bleeds easily . . . . . . . . . . . . . . . . . . . . . . . . . Yes Swelling or soreness anywhere on the body . Yes Armpits or groin swelling . . . . . . . . . . . . . . . .       Yes

 

Patient’s History and Health Questionnaire

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