PATIENT HISTORY QUESTIONNAIRE
Please fill in as much as possible to facilitate your examination:
Name:____________________ Age:_______ D.O.B._______________ Today’s Date:________________
Chief Complaint: (describe briefly your present medical symptoms) ______________________________
_____________________________________________________________________________________
MEDICAL HISTORY: (Please check if you are allergic to any of the following)
Penicillin_______ Sulfa______ Aspirin ______ Tetracycline______ Codeine ______
Others: __________________________________ Any foods:____________________________
List any medications you are currently taking,
including vitamins, health supplements, herbal
medications, allergy injections, contraceptive
pills or injections:______________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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List any previous illnesses or hospital stays,
including chicken pox, rheumatic fever,
high blood pressure, diabetes, etc:
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
List any operations you have had and when, including tonsillectomy, appendectomy, C section, etc:
_____________________________________________________________________________________
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_____________________________________________________________________________________
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PERSONAL HISTORY:
Do you smoke? _____ If yes, how long? _____ How many packs per day? _____ Have you ever been a
smoker? _____ If so, when did you quit? _____ How much alcohol do you consume per week? _____
Do you now or have you ever used recreational drugs? ______________________________________
Do you wear a helmet when biking, skate boarding, etc.? _______ Do you eat balanced meals? _____
HEALTH MAINTENCE:
When was your last:
Tetanus injection________ Flu Vaccine_______ Pneumonia Vaccine________
What was your last cholesterol level? _________________ Do you have a living will? ______________
Have you ever had, and if so when:
EKG __________________ Chest X-Ray __________________
Sigmoidoscopy _________________ Eye exam ___________________ Dental exam _______________
FOR WOMEN ONLY:
Menstrual History: Age at onset or menopause: __________ Regular? ______ Cycle-days (from start to
finish) _________________ Usual duration? _________ Date of last period?______________________
Number of pregnancies? _______Do you plan future pregnancies? _________
How many children born alive?_________ Number of abortions or miscarriages? __________
Have you had a mammogram? ____ If yes, when? _________
Do you perform monthly self breast exam? ____
When was your last pap smear? _______ Have you ever had an abnormal pap smear or any type of
cervical treatment? ____ If yes, when? _______________ Do you take a calcium supplement? _______
FOR MEN ONLY:
Have you ever had prostate trouble? _____ Do you perform self testicle exams on a regular basis? _____
When was your prostate last checked? _____________________________________________________
Please check the following if you have or ever had:
_____ Eye disease
_____ Fainting spells
_____ Loss of consciousness
_____Dizziness
_____ Depression or anxiety
_____ Enlarged glands
_____ Trouble with nose, sinuses,
mouth, throat
_____ Convulsions
_____ Paralysis
_____ Frequent or severe headaches
_____ hallucinations
_____Allergies
_____Skin disease
_____ Chronic or frequent
cough
_____ Night Sweats
_____ Vomiting or cough up of blood
______ Difficulty sleeping
______ Shortness of breath
______ Swelling of hands or feet
______ Indigestion
______ Enlarged thyroid or goiter
______ Frequent nosebleeds
______ Palpitations or fluttering heart
______ Chest pain or angina pectoris
______ Easy bruising
______ Bleeding gums
_____ Extreme tiredness or weakness
_____ Hemorroids or rectal
_____ Liver or gall bladder disease
Bleeding
_____ Constipation or diarrhea
_____ Frequent urination
_____ Blood in urine
_____ Burning with urination
_____ Bladder or kidney stones
_____ Sexually transmitted disease _____ Asthma
_____ Hay fever
_____ Wheezing
FAMILY HISTORY
IF LIVING:
LIVING IN
RELATIVE
AGE
ANY ILLNESSES
_____ Trouble swallowing
_____ Stomach trouble or ulcer
_____ Colitis or other bowel disease
_____ Abdominal pain
_____ Difficulty controlling urine
_____ Loud snoring
IF DECEASED:
AGE & CAUSE OF DEALTH
SAME
HOUSEHOLD?
Father
Mother
Brother(s) or Sister(s)
Spouse
Children
If any blood relative has had any of the illnesses listed below, please specify which relative(s):
Cancer________________ Tuberculosis _____________________ Suicide______________Arthritis____________
Diabetes_______________ Heart trouble________________ Nervous breakdown/depression________________
Schizophrenia_______________ Stroke_________________ Leukemia_________________ Asthma___________
High blood pressure_________________ Epliepsy_________________ Birth defects/congenital heart__________
Bleeding tendency__________________ Senility/Alzheimer’s_________________ Colitis_____________________
Kidney disease/kidney failure____________________ Alcoholism_________________ Osteoporosis____________