Patient Health Questionnaire
Name: _________________________________________ Date of Birth: ______/_______/______
Do you have any medication allergies?
____ Yes
____ No
If so, please list: ______________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Review of Systems:
To the best of your knowledge, do you now have or have you ever had the following:
Yes
No
CONSTITUTIONAL
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Curvature of the Spine
Arthritis/Joint Pain
Difficulty Walking
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Bruise Easily
Psoriasis
Eczema
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Liver Disease
Stomach Ulcer
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PSYCHOLOGICAL
Depression
Drug/Alcohol Dependency
Psychiatric Treatment
ENDOCRINE
Diabetes
Thyroid Disorder
HEMATOLOGIC/LYMPH
Anemia
Swollen Glands
Immune Disease/AIDS
Blood Clots
Chronic Heartburn
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Pulmonary Emboli
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Unexplained Chills
Unexplained Fever
Significant Weight Gain
Significant Weight Loss
EYES
Double Vision
Vision Problems
RESPIRATORY
Asthma or Wheezing
Shortness of Breath
Chronic Cough
Sleep Apnea
GI TRACT
Hiatal Hernia
GENITAL/URINARY
Urinary Tract Infection
Kidney of Bladder Disease
Difficulty Urinating
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NEUROLOGIC
CARDIAC
High Blood Pressure
Heart Attack
Irregular Heart Rate
Pacemaker
Rheumatic Fever
No
SKIN
EAR/NOSE/THROAT
Lack of Sense of Smell
Hearing Loss
Yes
MUSCULAR/SKELETAL
Polio
Stroke
Head Injury
Numbness of Arm/Leg
ALLERGY/IMMUNOLOGIC
Iodine
Shellfish
Latex
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SOCIAL HISTORY
Do you smoke? ____ Yes
____ No (Number of packs/day ____ for ____ years)
Do you drink?
____ Yes
____ No (Number of drinks/week ____)
Are you married ____ Yes
____ No Do you live alone? ____ Yes ____ No
Level of Education: ____________________________________________________________________________________________________________
PAST HISTORY
Any medical history not covered in previous questions? _______________________________________________________________________________
____________________________________________________________________________________________________________________________
Are you pregnant or think you may be? ____ Yes ____ No
Surgeries/Hospitalization
Reason
Year
1. __________________________________________________________________________________________________________________________
2. __________________________________________________________________________________________________________________________
3. __________________________________________________________________________________________________________________________
4. __________________________________________________________________________________________________________________________
Medication that you are currently taking:
Medication
Dosage
When you started taking
1. __________________________________________________________________________________________________________________________
2. __________________________________________________________________________________________________________________________
3. __________________________________________________________________________________________________________________________
4. __________________________________________________________________________________________________________________________