BEACHES ACU-MEDICAL CENTER HEALTH HISTORY QUESTIONNAIRE
PATIENT NAME: _________________________________________________________ Date: ______________
If minor, parent/guardian name: _________________________________________________________________
ADDRESS: ________________________________________________________________________________
__________________________________________________________________________________________
EMAIL ADDRESS: __________________________________________________________________________
PHONE Home: _________________________ Work:______________________ Cell: _____________________
Age: ______ DOB: ____________________ Time of birth _____________ Place of birth: _________________
Occupation: _____________________________________ Marital Status: ______________________________
Emergency contact: __________________________________________________________________________
Other health care providers: ___________________________________________________________________
__________________________________________________________________________________________
MAIN PROBLEM & REASON FOR CONSULT:
how long
first onset
diagnosis given
therapies tried
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How do you rate your current level of health?
(very poor)
1
2
3
4
5
6
7
8
9 10
(excellent)
8
9
(excellent)
How do you rate your current level of energy?
(very poor)
1
2
3
4
5
6
7
10
Please check any of the following if they apply to you:
____
Are you tired?
____
Do you fatigue easily?
____
Do you need to take naps?
____
Do you generally feel cold?
____
Do your hands or feet get cold?
____
Do you ever have low grade fever?
____
Do your hands or cheeks warm up easily?
____
Do your feet get warm in bed during the night?
____
Do you ever wake up sweating during the night?
Approximate number of servings per day?
____
animal protein
____
vegetables
____
carbohydrates
____
fruit
____
sweets
____
snacks
Please list approximate daily amounts:
________________
water
________________
soda/carbonated
________________
caffeine
________________
herbal tea
________________
milk
________________
fruit or vegetable juices
________________
alcoholic beverages: type ___________________________
List FOOD ALLERGIES:
What is your blood type? __________ (O, A, AB, B)
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Please check any of the following that apply to you:
____
poor appetite
____
poor digestion
____
appetite recently changed
____
belching
____
flatulence/gas
____
difficulty swallowing
____
heartburn
____
hernia
____
esophageal reflux
____
foul stools
____
bad breath
____
peculiar taste in mouth
____
feel bloated
____
craves sweets
____
loss of taste/smell
____
mouth sores
____
dry mouth
____
thirst not quenched by water
____
swollen tongue
____
cracked tongue
____
teeth marks on tongue
____
constipation
____
hemorrhoids
____
blood/pus in stools
____
ulcers
____
ulcerative colitis
____
irritable bowel syndrome
____
epigastric distension (stomach)
____
abdominal distension (intestinal)
____
nausea after eating
____
headache after eating
____
hypoglycemic blood sugar lows
____
gallbladder congestion or gallstones
____
dark urine
____
burning with urination
____
incontinence
____
trouble urinating
Please check any of the following that apply to you:
____ insomnia
____
restless sleep
____
trouble getting to sleep
____
snoring
____
light sleeper
____
dream-disturbed sleep
____
wakes tired
____
wakes rested
____
wake at night to urinate
____
less than 6 hours sleep per night
____
mood swings
____
anxiety
____
depression
____
stressed out
____
worried sick
____
grieving; melancholy
____
thinks too much
____
fears/phobias
____
repetitive thoughts
____
ADD
____
trouble focusing
____
obsessive compulsive
____
memory loss
____
stressful job
____
stressful relationships
____
Have you had any significant illnesses in your life:
If so, please list:
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need more than 8 hours sleep per night
Yes
No
ACCIDENTS including fractures, deep cuts, emotional traumas, falls. Include dates and/or age:
SURGERY HISTORY
including minor/major, cosmetic, routine. Include dates and/or age:
Do you have ALL of your body parts (i.e., gallbladder, tonsils, appendix, uterus)?
Yes
No
If no, please list:
Do you have ADDITIONAL body parts (i.e., breast implants, joint replacement, pins)?
Yes
No
Yes
No
If yes, please list:
Have you ever had BOTOX injections or CORTISONE injections?
If yes, please list:
Do you suffer from chronic or occasional
____
low back pain
____
hip or knee pain
____
neck pain or stiffness
____
shoulder pain
____
rheumatism
____
muscles aches or cramps
____
headaches
____
TMJ
____
bursitis or tendonitis
____
fibromyalgia
____
arthritis
____
sciatic pain
____
shooting pains
____ moving pains
____
dull pains
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Please check if you have or have ever had any of the following:
Now
Past
Now
Past
____
____
allergies, hives
____
____
head injury
____
____
anemia
____
____
headaches
____
____
asthma, breathing difficulty
____
____
heart murmur
____
____
bruise or bleed easily
____
____
heart palpitations
____
____
cancer, tumors, warts
____
____
hepatitis
____
____
candida
____
____
herpes
____
____
cholesterol high
____
____
hypertension
____
____
chronic fatigue
____
____
hypotension
____
____
constipation
____
____
kidney stones
____
____
depression
____
____
low sex drive
____
____
diabetes
____
____
mental illness
____
____
digestive problems
____
____
mononucleosis
____
____
dizziness, vertigo
____
____
nose bleeds
____
____
dry eyes, skin, hair, lips
____
____
neuropathy, numbness
____
____
edema, fluid retention
____
____
parasites
____
____
encephalitis
____
____
prostate problems
____
____
epilepsy, seizures, faint
____
____
sexual abuse
____
____
frequent colds
____
____
skin problems, acne, psoriasis
____
____
gallstones
____
____
STDs
____
____
gout
____
____
urinary tract infection
____
____
hair loss
____
____
weight gain or loss
Yes
No
Yes
No
Yes
No
Have you ever received a FLU SHOT ?
If so, how many and when was the last one?
Have you ever received any TRAVEL VACCINES?
If so, which vaccines and when?
Have you ever received the HEPATITIS VACCINE?
If so, when?
Other recent vaccinations:
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Please indicate current or previous use of the following:
Now
Past
Years used
____
____
allergy medications
_______
____
____
antacids
_______
____
____
antibiotics
_______
____
____
antidepressants
_______
____
____
birth control pills
_______
____
____
blood pressure meds
_______
____
____
hormone replacement
_______
____
____
pain medications
_______
____
____
sleeping aids
_______
____
____
statins/cholesterol
_______
____
____
steroids (predisone, etc.)
_______
____
____
thyroid medication
_______
____
____
Viagra type meds
_______
____
____
alcohol in excess
_______
____
____
cigarettes
_______
____
____
amphetamines
_______
____
____
cocaine
_______
____
____
marijuana
_______
____
____
LSD, heroin, other
_______
Frequency/Brand, etc.
Family History (father, mother, sibling, grandparent):
____
____
cancer
F
M
S
GP
____
____
stroke
F
M
S
GP
____
____
heart – blood pressure
F
M
S
GP
____
____
asthma
F
M
S
GP
____
____
Alzheimer’s
F
M
S
GP
____
____
diabetes
F
M
S
GP
____
____
arthritis
F
M
S
GP
____
____
suicide
F
M
S
GP
If parents deceased, state age of death and cause:
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Women’s Health: Please check if you have or have ever had any of the following:
Now
Past
Now
Past
____
____
amenorrhea
____
____
menstrual cramps
____
____
breast augment/reduction
____
____
miscarriage
____
____
endometriosis
____
____
nipple discharge
____
____
fibrocystic breasts, lumps
____
____
ovarian cysts
____
____
heavy uterine bleeding
____
____
pelvic inflammatory disease
____
____
hot flashes
____
____
PMS
____
____
infertility
____
____
uterine fibroids, warts, herpes
____
____
irregular PAPs
____
____
vaginal or yeast infections
____
____
irregular periods
____
____
vaginal dryness
Number of pregnancies: ____
Number of days between periods: _____
Number of miscarriages: ____
How long does your period last? _________
Number of abortions: ____
Number of children: _____
Other relevant history:
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