Get Back To Being You!
Health History Questionnaire
Name:
Date:
Past History
Check if you’ve had….
Rheumatic Fever
Heart Murmur
High Blood Pressure
Disease of the arteries
Heart Attack
Chest Pain
Stroke
Cancer
Lymphedema
Lung Disease
Epilepsy
Diabetes
Varicose Veins
Injuries to Back
Injuries to Knees, etc.
Surgery
Other
Family History
Present Symptoms/Conditions
(Including parents, grandparents,
siblings)…
Have any relatives had…
Heart Attacks
High Blood Pressure
Heart Operations
Congenital Heart Disease
Cancer
Diabetes
Other Major Illness
Do you experience…
Chest Pains
Heart Palpitations
High Blood Pressure
Cancer
Lymphedema
Shortness of Breath
Back Pain
Arthritis
Swollen Legs
Other
Explain each checked item:
____________________________
HOSPITALIZATIONS/SURGERIES
List all reasons you were hospitalized
Year
(excluding your cancer diagnosis/treatment)
1. __________________________
_____
2. __________________________
_____
3. __________________________
_____
4. __________________________
_____
4. ___ 5.___________________________
_____
ALL ALLERGIES REACTION
(MEDICATIONS/FOODS/ETC)
1. ___________________ ________________
2. ___________________ ________________
3. ___________________ ________________
4. ___________________ ________________
5. ___________________ ________________
MEDICATIONS
(List all medication you take on a regular basis including over the counter medications)
1. _______________________________________ Reason: ________________________________________
2. ________________________________________ Reason: _________________________________________
3. _______________________________________ Reason: ________________________________________
4. _______________________________________ Reason: ________________________________________
**If you need additional space,Reason:
please use
another sheet of paper**
5. _______________________________________
________________________________________
Get Back To Being You!
Please circle any symptoms you are currently experiencing or mark the circle if you are not
experiencing any of these symptoms.
Category
Symptoms
No Symptoms
General
Appetite change Fatigue
Weight gain Weakness
Skin
Itching
Eyes
Vision change
Ears/Nose/Mouth
Dizziness Ringing in ears
Nosebleeds
Lungs
Cough Shortness of breath
Wheezing
Heart
Chest pain
GI
Abdominal pain Nausea Vomiting Diarrhea
Jaundice Blood in stool Difficulty swallowing
Urinary
Painful urination
Kidney stones
Musculoskeletal
Arthritis
Nervous System
Headache Seizure Dizziness Memory loss
Numbness/tingling Anxiety Depression Personality change
o
Reproductive
(M) Testicular pain (M) Swelling
(W) Abnormal bleeding
o
Hematologic
Bruising
Lymph Nodes
Enlargement
Fever
Sweats
Weight loss
o
Mole change
o
Cataracts
o
Rash
Palpitations
Glaucoma
Sore throat
Chest pain Coughing up blood
Bleeding
Swelling
o
o
o
Fainting
Increased frequency
Stiffness
Runny nose
Urgency
Weakness
Constipation
Blood in urine
Backache
(W) Pelvic pain
Recurring infections
Tenderness
**If you need additional space, please use another sheet of paper**
o
o
o
o
o