Original Date:
Spokane Psychiatric Clinic, P.S.
Dates Revised:
HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.
Name
 M
(Last, First, M.I.):
Marital status:
 Single
 Partnered
 Married
 Separated
Previous or referring doctor:
 Divorced
 F
DOB:
 Widowed
Date of last physical exam:
PERSONAL HEALTH HISTORY
List any medical problems that other doctors have diagnosed
Surgeries
Year
Reason
Hospital
Other hospitalizations
Year
Reason
Hospital
Have you ever had a blood transfusion?

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Name the Drug
Strength
Allergies to medications
Name the Drug
Reaction You Had
Frequency Taken
Yes

No
HEALTH HABITS AND PERSONAL SAFETY
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE 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)
Caffeine
 None
 Coffee
 Tea
 Cola
# of cups/cans per day?
Alcohol
Do you drink alcohol?

Yes

No
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
Do you use tobacco?

Yes

No
If yes, what kind?
How many drinks per week?
Tobacco
 Cigarettes – pks./day
 # of years
Drugs
Personal
Safety
 Chew - #/day
 Pipe - #/day
 Cigars - #/day
 Or year quit
Do you currently use recreational or street drugs?

Yes

No
Have you ever given yourself street drugs with a needle?

Yes

No
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 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
AGE
SIGNIFICANT HEALTH PROBLEMS
AGE
Children
Father
Mother
Sibling












M
F
M
F
M
F
M
F
M
F
M
F
Grandmother
Maternal
Grandfather
Maternal
Grandmother
Paternal
Grandfather
Paternal








M
F
M
F
M
F
M
F
SIGNIFICANT HEALTH PROBLEMS
MENTAL HEALTH
Is stress a major problem for you?

Yes

No

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
Do you feel depressed?
Please rate your depression - on a scale of 1-10 - with 0 being none and 10 being worst ever/couldn’t be worse
__________
REVIEW OF SYSTEMS
Circle those items you currently have problems with, and describe:
GENERAL
Recent Weight Change
Increased Thirst or Urination Night Sweats/Hot Flashes
Always Hot/Always Cold
Rashes or Skin Problems
Do you have chronic pain problems? Yes No
Significant Fatigue
BREASTS: Men & Women
Lumps/Tenderness
EYE, EAR, NOSE, AND THROAT
Glaucoma Blurred or Double Vision- Ever Use Glasses or Contact Lenses
Hearing Loss
Brief Loss of Vision- Ever
Use Dentures (Partial or Total)
History of Radiation Therapy to Head or Neck
Teeth or Gum Problems
CARDIOPULMONARY
Shortness of Breath With Activity
Dizziness Chest Pain
Daily Sputum (Phlegm) Production
Coughing Up Blood Heart Palpitations
Difficulty Breathing While Lying Flat
Leg Cramps While Walking
Wheezing
Waking Up Short of Breath
Daily Cough
Ankle Swelling
GASTROINTESTINAL
Change of Appetite
Abdominal Pain
Blood in Stool/Black Stool
Difficulty Swallowing
Diarrhea/Constipation
Heartburn Indigestion From Fatty Foods
Frequent Nausea/Vomiting
NEUROPSYCHIATRIC
Frequent Disabling Headaches Difficulty Sleeping Tremors
Frequent Anxiety or Anxiety Attacks
Memory Loss
Passing Out/Fainting
Treated in Past for Emotional or Psychological Problems: please describe _____________ Often Feel Sad or Depressed
MUSCULOSKELETAL & SKIN
Frequent Neck or Back Pain Muscle Pain
Disabling Night Leg Cramps
Joint Problems
Use a Brace or a Splint
Mole that has changed color, size, shape, or won’t heal? Yes No
GENITOURINARY: MEN & WOMEN
Urinary Tract Infections
Sores in the Genital Area
Difficult or Painful Urination Blood in Urine
History of Kidney or Bladder Stones
Urination More Than Once a Night
GENITOURINARY: MEN ONLY
Pain or Lump in Testicles/Scrotum
GENITOURINARY: WOMEN ONLY
Number of Pregnancies: ____________ Number of Children: ________
Disabling Menstrual Cramps
PMS Symptoms