PATIENT HEALTH QUESTIONNAIRE
NAME_________________________________ DATE of BIRTH_________________DATE____________
PLEASE TRY TO ANSWER ALL QUESTIONS ON BOTH SIDES. THIS INFORMATION WILL BE
TREATED AS CONFIDENTIAL
PAST HEALTH
Have you ever suffered from any of the following conditions?
Yes No
Yes No
Anemia
Thyroid Trouble
Diabetes
Rheumatic Fever
High Blood Pressure
Heart Disease
Tuberculosis
Pneumonia
Stomach Ulcers
Kidney Disease
Yes
No
Back Pain
Emotional Problems
Epileptic Seizures
Allergies
Jaundice
(infections)
Do you take any medications regularly? Yes No If yes, please list:_________________________________
_________________________________________________________________________________________
Alcohol use?
Yes No
Illicit Drug use? Yes No
Amount:___________________________
Type:______________________________
Please list any significant illnesses or operations you have had.
Date
Illness or Operation
Doctor and/or Hospital
_____________________
_____________________________________________
________________________________
_____________________
_____________________________________________
________________________________
_____________________
_____________________________________________
________________________________
_____________________
_____________________________________________
________________________________
_____________________
_____________________________________________
________________________________
FAMILY HEALTH
Age
Father
Mother
Health Problems
If Deceased,
Cause of Death
Age
at Death
Has any Blood Relative Had
Tuberculosis
Heart Disease
High Blood Pressure
Brothers
and
Sisters
Alcoholism
Kidney Disease
Diabetes
Strokes
Children
Epilepsy
Mental Illness
Allergies
Lung Disease
Page 1 of 2
Y N
PATIENT HEALTH QUESTIONNAIRE
Are you affected by any of the following?
Yes No
Fatigue
Loss of Appetite
Loss of Weight
Fever
Chills
HEAD & NECK
Yes No
Headaches
Eye Trouble
Hearing Difficulty
Earaches
Sinus Trouble
RESPIRATORY
Yes No
Cough
Sputum
Bloody Sputum
CARDIOVASCULAR
Yes No
Shortness of Breath
Chest Pain
Palpitations
DIGESTIVE
Yes No
Difficulty Swallowing
Heartburn
Nausea
Vomiting
URINARY
Yes No
Frequency of Urination
Painful Urination
LOCOMOTOR
Yes No
Pain, stiffness, joint swelling
Limitation joint movement
NERVOUS SYSTEM
Yes No
Forgetfulness
Nervousness
Depression
Spells of Any Kind
WOMEN ONLY
Yes No
Irregular Menstruation
Painful Menstruation
Very Heavy Periods
Bleeding between Periods
Page 2 of 2
Yes No
Night Sweats
Intolerance to Heat
Intolerance to Cold
Any Skin Trouble
Fainting
Yes No
Difficulty Sleeping
Bleeding Tendency
Date of Last Tetanus Shot
Date of Late Polo Shot
Yes No
Nasal Congestion
Nose Bleeds
Hay Fever
Dental Trouble
Sore Tongue
Yes No
Frequent Colds
Sore Throat
Lumps in Neck
Neck Pain
Yes No
Wheezing
Shortness of Breath
Date of last TB test
Yes No
Cigarette Smoking
Number Daily?
Date of last Chest X-Ray
Yes No
Swelling of Ankles
Pains in Legs
Varicose Veins
Yes No
Have you ever has an EKG
(Electrocardiogram)? When?
High Blood Pressure
Yes No
Abdominal Pain
Gas
Constipation
Diarrhea
Yes No
Bloody Stools
Black Stools
Do you take Laxatives?
Do any foods cause indigestion?
Yes No
Change of Urine Appearance
Incontinence
Yes No
Getting up at night to urinate?
How Many Times?
Yes No
Any broken bones?
Foot Trouble
Yes No
Back Pain
Deformities
Yes No
Abnormal Sensations
Loss of Balance
Clumsiness
Muscle Weakness
Yes No
Difficulty Walking
Tremors
Dizziness
Yes No
Are You Passed Menopause
Abnormal Discharge
Do you take Birth Control
Pills
Any trouble with Breasts
Number Of Pregnancies
Number Of Miscarriages
Date of last Menstrual Period
Date of Last Pap Smear