1
VDH CONFIDENTIAL HEALTH HISTORY
INITIAL DATE :_________________________
SECTION 1. CHECK BELOW IF YOU OR ANY FAMILY MEMBER HAVE THESE:
YOU FAMILY
YOU FAMILY
OFFICE USE ONLY
1. Allergies (food, insects, drugs, latex)
na
21. Head or spinal injury
na
2. Allergies (seasonal)
na
22. Hearing problems/Deafness
na
3. Anemia (low blood iron)
na
23. Heart problems/Murmurs
4. Arthritis
na
24. Hepatitis or liver disease
5. Asthma/Bronchitis/Pneumonia
na
25. High blood pressure/stroke
6. Congenital/Genetic DisordersCerebral Palsy/Cystic Fibrosis/Down
syndrome
26. Intellectual disability/learning
problems
7. Bladder/kidney problems
na
27. Mental Health issues/ Mental
illness/Depression/Suicide/Anxiety
Depression after giving birth
na
8. Blood Clots (legs or lungs)
na
28. Frequent/ Migraine headache
na
9. Blood disease or bleeding problem
10. Bone problems
29. Muscle/joint problems
na
11. Cancer *
30. Seizures/epilepsy
31. Sickle cell trait or disease
na
a.* Breast Cancer
32. Skin problems
b. * Ovarian Cancer
33. Sexually transmitted
infection/HIV
14. Developmental Delay/Autism
34. Surgery
na
15. Diabetes (sugar)
35. Throat problems
na
16. Diarrhea/Constipation/Bowel
problem
na
36. Thyroid problems
17. Drug/Alcohol/Tobacco use
na
37. Tuberculosis/other lung problem
na
18. Eating of non-food items
na
38. Vision/Eye problems
na
19. Feeding problems/special diet
na
39. Colposcopy/ LEEP/Cryotherapy
na
20. Gall bladder
na
40. Other

*Complete questions on page 2 if a positive response.
Check any of these that you now use, or that you have ever used: cigarettes/tobacco products____, over-the-counter medicines____,
herbal remedies____, medicines from other countries____, alcohol/beer/wine/liquor____, amphetamines/diet pills/speed____, steroids____,
marijuana/hashish____, cocaine/crack____, sedatives/tranquilizers____, narcotics____, drugs that you inhale____,
drugs that make you see things____ , drugs that you inject____.
In the past, have you been hit, pushed, slapped, choked, sexually abused, or otherwise physically hurt by anyone, including someone you were
dating or going out with? YES _____ NO _____
In the past, has anyone made you have sex (vaginal, oral or anal sex) when you didn’t want to, including someone you were dating or going out
with? If yes, did the person use threats or force to make you have sex? YES _____ NO _____
Have you ever been hospitalized? YES ____ NO _____ If YES; List dates and why_________________________________________________________
Your family doctor: ___________________________________________________________________________________________________________________
Are your immunizations current? YES ____ NO _____ Is transportation a problem for you? YES ____ NO _____
Country of Birth, Primary Language Spoken______________________ Current Occupation/School ________________________________________
How do you prefer your health information _____Written, _____Spoken, ____Other
Do you live in house____ apartment____ mobile home/trailer____ motel____ shelter ____ other ______________________________________
What type of heat do you have? _________________________ Home has: Refrigerator ____ Stove____ Running Water____ Indoor plumbing____
Water Source is: well____ public ____ other_____________ Number of persons living in household: ____
Does anyone in the household smoke? YES____ NO ____
Is there a smoke alarm in the home? YES _____ NO
Do you use a seat belt regularly? YES ____ NO ____
DATE
_________
_________
_________
_________
_________
follow-up review
NOTE:
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
NAME, ID # (LABEL)
INITIALS
___________
___________
___________
___________
___________
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VDH CONFIDENTIAL HEALTH HISTORY
Additional Breast and Ovarian Cancer Questions to ask when a patient identifies as having breast cancer, ovarian cancer or has identified a
family member with breast and/or ovarian cancer:
1.
2.
3.
Were you diagnosed with breast cancer_________
How old were you when this diagnosis was made_____________
Which breast was the cancer diagnosed: _____right, ____left, both right and left____________
Family members
1. Do one or more female members of your family have or ever had breast cancer_______ If so how many members_________
2. Do one or more female members of your family have or ever had ovarian cancer_______ If so how many members_____________
3. Do one or more female members of your family have both breast and ovarian cancer________________
4. Do one or more members of your family (female or male) have a diagnosis of two types of primary cancer________________ If so how
many family members____________
5. If yes list what type of cancers they have:_____________________________________________________________________________________________________
ADDITIONAL FINDINGS:
Form 15-2 (Revised)
NAME, ID # (LABEL)