Health History Questionnaire
All answers are strictly confidential and will become part of your medical record.
M
Patient Name: ____________________________________
DOB:
_____ / _____ / _______
Right-Handed
Your Referring Doctor: _____________________
F
Left-Handed
Date:
_____ / _____ / _______
Height: _______________
Other Treating Physicians: __________________________
CHIEF COMPLAINT
Please Give a Brief Description
of the Problem for which you
are seeking treatment:
 YES
Have You Had Any Testing or
Evaluations for this Condition?
 NO
Who Ordered the Tests or Performed an Evaluation? ___________________________________________
What Tests Were Performed? ______________________________________________________________
PERSONAL MEDICAL HISTORY
Medical Problems Previously Diagnosed -- If Yes, Please Explain.
Anemia: ________________________
Diabetes: _______________________
Liver: __________________________
Arthritis: _______________________
Depression: _____________________
Psychiatric: ______________________
Blood Pressure: __________________
Emphysema / Asthma: _____________
Seizure: ________________________
Cholesterol: _____________________
Heart: __________________________
Thyroid: ________________________
Cancer: ________________________
Kidney: _________________________
Vision: _________________________
Other: _________________________
Other: _________________________
Other: _________________________
Other Major Medical Events
Surgeries & Other Hospitalizations
Year
Please turn to the next page
Reason
Hospital
No Known Drug Allergies
Allergies to Medications
Name the Drug
Reaction You Had
FAMILY HEALTH HISTORY
Age
Living, Deceased, Health Problems
Father
Ag
e
Siblings
M
M
M
M
M
M
M
F
F
F
F
F
F
F
Children
M
M
M
M
M
M
M
F
F
F
F
F
F
F
Mother
Grandfather
Maternal
Grandmother
Sex
Living, Deceased, Health
Problems
Maternal
Grandfather
Paternal
Grandmother
Paternal
SOCIAL HISTORY
Personal
Marital Status:
Single
Engaged
Educational Status:
High School Graduate
Work Status:
Full-Time
Married
Separated
Some College
Divorced
College Degree: __________
Widowed
Other:
____________
Part-Time
Student
Unemployed
Disabled
Retired
Occupation:
Caffeine
 None
Coffee
Tea
Cola / Soda
# of cups per day?
Alcohol
Do you drink alcohol?
Yes
If yes, what kind?
# of years
No
Or year quit
How many drinks per week?
Tobacco
Do you use tobacco?
Cigarettes – #/day
# of years
Drugs
Yes
Chew - #/day
Pipe - #/day
No
Cigars - #/day
Or year quit
Do you currently use recreational or street drugs?
Yes
No
Have you ever given yourself recreation or street drugs with a needle?
Yes
No
Please turn to the next page
REVIEW OF SYMPTOMS
*** Place A  Check Beside Each Symptom You Have Recently or Currently Experienced ***
Constitutional Symptoms





Weight Loss or Gain
Fever
Daytime Fatigue
Sleep Difficulty
Loss of Appetite
Ear, Nose, & Throat Symptoms
Hearing Loss
Sinus Problems
Nose Bleeds
Sore Throat
Voice Change
Difficulty Chewing or
Swallowing
 Heavy Snoring






Cardiovascular Symptoms
 Chest Pain / Angina
 Palpitations
 Swelling of Feet,
Ankles, Hands
 Calf Pain while walking
 Have You Had A
Carotid Ultrasound?
Respiratory Symptoms




Frequent Cough
Spitting Up Blood
Shortness of Breath
Asthma or Wheezing
Recent Vaccinations
 Flu Vaccine
 Shingles Vaccine
 Pneumonia Vaccine
Gastrointestinal Symptoms
 Abdominal Pain
 Heartburn
 Nausea/ Vomiting
 Frequent Diarrhea
 Rectal Bleeding
 Blood in Stool
 Recent
Colonoscopy
Genitourinary Symptoms




Frequent Urination
Painful Urination
Blood in Urine
Incontinence
Skin Symptoms
 Rash or Itching
 Change in Hair
 Change in Nails
Hematologic Symptoms
 Excessive Bleeding
 Easy Bruising
 Past Transfusions
Endocrine Symptoms
 Excessive Thirst
 Heat Intolerance
 Cold Intolerance
Diabetes
 Are You Diabetic?
If You Are Diabetic:
 Recent Eye Exam
Date: ________
 Recent A1C Check
Date: ________
Psychiatric Symptoms



Depression
Anxiety
Hallucinations
Musculoskeletal Symptoms
 Joint Pain or
Stiffness
 Muscle Pain or
Cramps
 Neck Pain or
Stiffness
 Lower Back Pain
Neurological Symptoms








Dizziness or Vertigo
Loss of
Consciousness
Seizure
Numbness / Tingling
in Arms or Legs
Tremor
Decreased Balance or
Falls
Frequent Headaches
Memory Loss or
Confusion
Vision Symptoms




Changes in Vision
Visual Loss – R or L
Double Vision – R or L
Blurry Vision – R or L