Kidder County Community Health Center Health Questionnaire
Todays Date:__________________
Patient Name:_______________________________________________Date of Birth:______________________________________
Do you have any allergies? If yes, please list: _______________________________________________________________________
Drug store preference: _________________________________________________________________________________________
Who is your primary doctor or care provider?________________________Last yearly exam?_______________________________
Do you see any specialists? If yes, for what?_______________________________________________________________________
Who is your dentist?____________________________ Date of last dental check-up and cleaning:___________________________
Please List the dates of last exams and any abnormal results found:
Last colonoscopy:__________________________________
Last EKG:_________________________________________
Last Chest X ray____________________________________ Last Bone Density Screening:_________________________
Last gynecologic exam:______________________________ Last eye exam:_____________________________________
Last Mammogram:___________________________________ Last Lung Function Screening:_________________________
Vaccination History
Date of last flu vaccination:__________________________________
Date of last pneumonia vaccination:___________________________
Date of last Tetanus vaccination:______________________________
Have you had the Shingles vaccine? ___________________________
Past Medical History: Do you have any previously diagnosed medical conditions? Please circle.
Asthma
Heart Attack
Migraines
Macular Degeneration
Pneumonia
Stroke
Seizures
GERD
COPD
Rheumatic Fever
Epilepsy
Hiatal Hernia
Chronic Lung Disease
Angina (Chest Pain)
Malnutrition
Gall bladder disease
Tuberculosis
High cholesterol
Vit D Deficiency
Urinary frequency
Tobacco Abuse
Osteoporosis
Glaucoma
Urinary incontinence
Shortness of Breath
Chronic neck pain
Cancer
BPH
Congestive Heart Failure Chronic back pain
Glaucoma
Kidney stones/infections
Anticoagulant Use
Arthritis
Cataracts
Chrohn’s Disease
Thrombosis (blood clot)
Carpal Tunnel
Tonsillitis
Ulcerative colitis
Bleeding disorder
Osteopenia
Lactose intolerance
Irritable bowel syndrome
High blood pressure
Rheumatoid Arthritis
Bee sting allergy
Chronic bladder infections
Atrial Fibrillation
Fibromyalgia
Hyperthyroidism
Diverticulitis
Pacemaker
Restless leg syndrome Hypothyroidism
GI Bleed
Heart murmur
Insomnia
Liver Disease
Erectile dysfunction
Palpitations
Depression
Jaundice
Hypogonadism
Anemia
Anxiety
Hepatitis
Meningitis
Low Iron
Psychiatric Illness
Pancreatitis
Bowel obstruction
Diabetes Type:__
High stress life style
Ulcers
Child birth: #________
Please list any other conditions not listed above:
Constipation
Chronic ear problems
Eczema
Irregular Pulse
Hearing loss
Multiple Sclerosis
Breast Cancer
Dementia
Alzheimer’s
Opiate Addiction
Gout
Pregnancy
Renal Failure
Shingles
Urinary Retention
Dehydration
Influenza A/B
Edema (swelling)
Menopause
Where you previously injured? If yes, please list injuries and approximate dates. (Ex: Any broken bones, head injuries, accidents.)
Have you been hospitalized for any reason? If yes, please explain.(Ex: surgeries, births, emergencies).
Have you ever had surgery? If yes, please explain. (Scheduled or emergency.)
Past Family Medical History: Do you have any family previously diagnosed medical conditions? Please circle.
Asthma
Heart Attack
Migraines
Macular Degeneration
Pneumonia
Stroke
Seizures
GERD
Chronic ear problems
Psychiatric Illness
COPD
Rheumatic Fever
Epilepsy
Hiatal Hernia
Eczema
Chronic Lung Disease
Angina (Chest Pain)
Malnutrition
Gall bladder disease
Irregular Pulse
Tuberculosis
High cholesterol
Vit D Deficiency
Urinary frequency
Hearing loss
Tobacco Abuse
Osteoporosis
Glaucoma
Urinary incontinence
Multiple Sclerosis
Shortness of Breath
Chronic neck pain
Cancer
BPH
Breast Cancer
Congestive Heart Failure Chronic back pain
Glaucoma
Kidney stones/infections
Dementia
Anticoagulant Use
Arthritis
Cataracts
Chrohn’s Disease
Alzheimer’s
Thrombosis (blood clot)
Carpal Tunnel
Ulcerative colitis
Opiate Addiction
Meningitis
Bleeding disorder
Osteopenia
Lactose intolerance
Irritable bowel syndrome
Gout
High blood pressure
Rheumatoid Arthritis
Bee sting allergy
Chronic bladder infections Atrial Fibrillation
Fibromyalgia
Hyperthyroidism
Diverticulitis
Renal Failure
Pancreatitis
Pacemaker
Restless leg syndrome Hypothyroidism
GI Bleed
Shingles
Heart murmur
Liver Disease
Urinary Retention
Palpitations
Depression
Jaundice
Diabetes Type:__
Ulcers
Bowel obstruction
Edema (swelling)
Anemia
Anxiety
Hepatitis
Low Iron
Social History:
Please circle the statement that best describes your smoking status.
Never a smoker
Former smoker-Please list quit date:___________________
Current some days smoker
Current every day smoker
If you are a current smoker please indicate the number of packs per day you smoke:______
For how many years have you smoked this many packs:___________
If you are a current every day smoker please indicate date of last quit attempt:__________
If you are a current smoker please circle the statement below that best summarizes you readiness to quit.
Not interested in quitting
Ready to quit
Thinking about quitting.
Would you like information on quitting today? Circle one:
Yes
No
Are you exposed to second hand smoke?
Current
Parent
Former
Partner
Never
Roommate
Spouse
Do you drink alcohol? Circle one: Yes No
If yes, what type:_________________ Number of drinks per week:_____________
Have you ever abused drugs? Circle one: Yes No
If yes, what type:_________________Length of time:________________________
Do you use caffeine (ex: coffee, tea, pop)? Circle one: Yes No
If yes, what type:_________________Amount per day:_______________________
Do you use your seat belt? Circle one: Yes
No
Do you use energy drinks? Circle one: Yes
No