MEDICAL HISTORY QUESTIONAIRE
Name:
DOB:
Date:
What is your occupation?
What are your concerns for today’s visit?
Please answer the following to the best to your ability.
1.
2.
3.
What is your gender?
Male
Female
How is your health?
Good
Fair
Do you have any ALLERGIES to any medications? _____Yes or
If so, please list below and reaction:
4.
Do you smoke or have you ever smoked?
Yes or ______No
If so, how many?
Have you ever been treated for any of the following LUNG PROBLEMS?
Asthma
Chronic Cough
Tuberculosis
Wheezing
Emphysema
Shortness of breath
Chronic Bronchitis
Recent Pneumonia
Coughing up blood
Have you ever been treated for any of the following HEART PROBLEMS?
Chest pain or Angina
Heart Murmur
Rheumatic Fever
Stroke
Shortness of breath
High blood pressure
Low blood pressure
Heart attack
Heart failure
Leg swelling
Palpitations of fainting
Have you ever had or been treated for MUSCLE, BONE OR JOINT PROBLEMS?
Arthritis
Muscle Weakness
Neck problems
Cramps or spasms
Trouble opening mouth
Have you ever had or been treated for SKIN DISORDERS?
Eczema
Psoriasis
Skin Cancer
Have you ever had or been treated for DIGESTIVE TRACT PROBLEMS?
Ulcer disease
Hiatal hernia
Cirrhosis
Gastritis
Hepatitis
Pancreatitis
Chronic indigestion
Liver problems
Yellow jaundice
Have you ever had KIDNEY PROBLEMS, KIDNEY FAILURE, or ARE ON DIALYSIS?
Yes or
Have you ever had or been treated for PROLONGED OR UNUSUAL OR EASY BRUISING? _____ Yes or
Family history of:
Bleeding problems or hemophilia
Sickle cell anemia or trait
Have you ever had or been treated for PSYCHIATRIC PROBLEMS?
_____ Anxiety _____ Depression _____ Panic Attacks _____ Other Issues
Have you ever had or been treated for METABOLIC OR ENDOCRINE PROBLEMS?
_____Low blood sugar
_____Thyroid Disease
_____Diabetes mellitus _____Porphyria
Have you ever had or been treated for ALLERGY and/or INMUNOLOGY?
_____Nasal Allergies
_____Currently on allergy shots
_____Skin allergies
_____HIV/AIDS
Have you ever had or been treated for NEUROLOGIC PROBLEMS?
Convulsions/seizures/fits/epilepsy
Numbness/tingling/pain in arms/legs
Low back pain sciatica
Fibromyalgia
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Poor
No
No
No
Patient Name:
DOB:
17. Is there a FAMILY HISTORY of any of the following?
Heart attack
Diabetes
Hepatitis
Stroke
Seizures
Tuberculosis
Thyroid disease
High Blood Pressure
Bleeding disorders
Cancer (List):
Asthma
Hearing loss
Stomach ulcer
18. FEMALES ONLY: Last menstrual period:
Are you pregnant?
Yes or
No
Are you planning to get pregnant?
Yes or
No
19. Do you currently take any MEDICATION? If so, please list all the Prescription and Over-the-Counter:
20. Which pharmacy to you use?
Phone:
21. Have you ever had SURGERY? Please list below:
Date:
Operation:
Complications:
Date:
Operation:
Complications:
Date:
Operation:
Complications:
Date:
Operation:
Complications:
22. Have you ever had CANCER?
Yes or
No
Date:
Type:
Date:
Type:
23. Please provide the following medical information to the best of your ability. (Circle)
**For “Yes” responses, please check “current” if this symptom relates to the reason for your visit today.
Hearing Loss
Dizziness
Nasal Congestion
Post nasal drip
Hoarseness
Throat clearing
Difficulty swallowing
Headache
Fatigue
Swollen Glands
Depression
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Current
Current
Current
Current
Current
Current
Current
Current
Current
Current
Current
Ear noise
Ear pain
Sinus pressure or pain
Problem snoring, apnea
Throat pain
Cough
Heartburn
Weight loss or gain
Daytime sleepiness
Mental health problems
FOR OFFICIAL USE ONLY
Weight:
BP Sitting
Pulse:
PRESENT ILLNESS:
lbs
/
mm Hg
Temp:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Current
Current
Current
Current
Current
Current
Current
Current
Current
Current