Male – Annual Check-Up
Please complete the following questionnaire prior to seeing the Doctor for your check-up
Past Medical History
Age:
Gastrointestinal System
Cardiovascular System
Are you currently having any of the following
problems:
Are you currently having any of the following
problems:
High blood pressure
Heart disease
High cholesterol
Chest pain
Heart palpitations
Heart murmurs
Anemia (low iron)
Blood transfusions
Stroke
Varicose veins
Other:
Change in the size, color and/or firmness of
stools
Yes
No
Blood or mucous in stools
Yes
No
Tarry stools
Yes
No
Heartburn
Yes
No
Ulcer
Yes
No
Other:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Genitourinary System
Are you currently having any of the following
problems:
Respiratory System
Sexual problems (e.g.: getting/keeping erections,
completing intercourse etc.)
Yes
No
Difficulty with urine stream strength or urine
flow rate
Yes
No
Getting up frequently during the night to
urinate
Yes
No
Kidney stones
Yes
No
Other:
Are you currently having any of the following
problems:
Shortness of breath
Asthma
Emphysema
Tuberculosis
Other:
Yes
Yes
Yes
Yes
No
No
No
No
Integumentary System
Musculoskeletal System
Are you currently having any of the following
problems:
Are you currently having any of the following
problems:
Change in the size, color, and/or shape of a mole
or moles
Yes
No
Other:
Bothersome joint pains or diseases of your joints
(e.g.: arthritis)
Yes
No
Chronic foot pain
Yes
No
Osteoporosis
Yes
No
Bone Fractures
Yes
No
Hernia
Yes
No
Other:
Endocrine System
Are you currently having any of the following
problems:
Diabetes Type 1(insulin)
Diabetes Type 1(diet/pills)
Hypo/Hyperthyroidism
Gout
Hepatitis A
1
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Hepatitis B
Hepatitis C
Other:
Yes
Yes
Allergies
No
No
Do you suffer from any of the following:
Central Nervous System
Are you currently having any of the following
problems:
Falling
Yes
No
Memory
Yes
No
Periods of weakness, numbness, or inability to
talk
Yes
No
Convulsions/Seizures
Yes
No
Migraines
Yes
No
Other:
Are you currently having any of the following
problems:
Yes
Yes
Yes
Yes
No
No
Over 40 years old:
PSA (prostate screen)
Do you or have you had cancer Yes
No
If yes, please specify what type and when you
were diagnosed:
Never
Over 50 years old:
Test for occult blood in stool (FOBT test) Never
Bone density test:
Never
Colonoscopy screening: Never
Sexually Transmitted Disease
Are you currently having any symptoms or
concerns about any of the following problems:
Yes
Yes
Yes
Yes
Yes
Yes
Routine blood work:
Never
Fasting lipid/cholesterol Never
STD Screen:
Never
Chest X-Ray:
Never
Tuberculosis Test:
Never
ECG (EKG):
Never
Hearing Test:
Never
Dental Check-up:
Never
Eye Exam:
Never
Cancer
Chlamydia
Gonorrhea
HPV (genital warts)
Herpes Simplex Virus
HIV
Other:
Do you have an allergist ?
Date of your last allergy test:
Please indicate if (and when) you have had the
following tests performed:
Are you currently having any of the following
problems:
Yes
No
No
No
No
No
Recent Testing
No
No
No
No
Sensory Disease
Glaucoma
Other:
Yes
Yes
Yes
Yes
Yes
Are you allergic to penicillin
Yes
No
Do you think you might be allergic to penicillin
but are not sure ?
Yes
No
Are you allergic to stinging insects (e.g. bees,
wasps etc.)
Yes
No
If yes to any of the questions above were you
allergy tested?
Yes
No
Mental Health
Insomnia (past month)
Depression (diagnosed)
Anxiety
Mental Illness
If yes, please specify:
Other:
Allergies
Hives
Stuffy/runny nose
Hayfever
Itchy Eyes
No
No
No
No
No
Vaccination History
Have you had your tetanus shot in the last 10
years?
Yes
No
Did you get a flu shot this year? Yes
No
Over 65 years old:
Have you had your Pnuemovax Yes
2
No
Past Surgical History
Do you use any of the following recreational
drugs:
Marijuana
Yes
No
Cocaine
Yes
No
Opiates
Yes
No
Other:
Please list any surgeries you have undergone,
including the type of surgery, the date and any
complications that occurred:
Have you ever been hospitalized for anything
other than undergoing surgery Yes
No
If yes, please list the reason and date of
admission:
How many sexual partners have you had in the
last 12 months:
How many sexual partners have you had in your
lifetime:
Do you have sex with men
Yes
No
Medications
Please list all medications you are currently
taking, please indicate the name and dosage of
the drug:
Please list any current concerns you have about
your general health:
Social History
What is your occupation:
What is your marital status:
How many children do you have:
Have you ever used tobacco
Do you currently smoke
Yes
Yes
No
No
If Yes,
Number of cigarettes per day:
Number of years smoking:
Previous attempt to quit
Yes
No
On a scale of 1 to 10 (1 being ‘not ready to
change’ and 10 being ‘trying to change’) how
would you rate your motivation to quit smoking
at this time:
What are your reasons for wanting to quit (e.g.
health, children/spouse):
What are your concerns about quitting:
If No,
What date did you quit smoking:
How many years did you smoke:
Do you drink alcohol
Yes
No
If Yes,
How many drinks per week:
Have you ever felt you should cut down on your
drinking?
Yes
No
3
Family Medical History
Do you have a parent, brother or sister with a history of the following: (If yes, please indicate the age that
the problem, started to the ‘onset of the condition)
Cancers
Breast
Yes
Bowel-Intestine Yes
Thyroid
Yes
Uterus-womb Yes
Ovaries
Yes
Prostate
Yes
No
No
No
No
No
No
Parent Onset
Parent Onset
Parent Onset
Parent Onset
Parent Onset
Parent Onset
Brother Onset
Brother Onset
Brother Onset
Brother Onset
Brother Onset
Brother Onset
Sister Onset
Sister Onset
Sister Onset
Sister Onset
Sister Onset
Sister Onset
Heart Disease
Heart attack
Yes
Angina
Yes
Hypertension Yes
No
No
No
Parent Onset
Parent Onset
Parent Onset
Brother Onset
Brother Onset
Brother Onset
Sister Onset
Sister Onset
Sister Onset
Diabetes
Type 1 (insulin) Yes
Type 2 (diet) Yes
No
No
Parent Onset
Parent Onset
Brother Onset
Brother Onset
Sister Onset
Sister Onset
Glaucoma
Yes
No
Parent Onset
Brother Onset
Sister Onset
Asthma
Yes
No
Parent Onset
Brother Onset
Sister Onset
Other family (genetic) disorders:
4