Name:
Age:
Health Questionnaire
Medical Problems (Example: High Blood Pressure, Diabetes, Cancer, Heart Disease, or any condition
for which you take a medication)
Appointment Date:
Pregnancy History
[ ] None
Number of Pregnancies?
Living Children?
Miscarriages?
Abortions?
Complications?
Last Pap:
Last Mammogram:
Bone Density:
Colonoscopy:
Surgery - ALL (For Example:Tonsillectomy, Appendectomy, Hysterectomy, Hernia, Ovaries, Cosmetic Procedures, etc.)
[ ] None
Allergies to Medicine? [ ] None (If Yes, please explain type of reaction, i.e. hives, wheezing, upset stomach, swelling)
Current Prescription Medicines
Name of drug
Mg / dosage
[ ] None
Gynecology History
Age at first period
Onset of last menstrual period
Are cycles regular? Y N
Heaviness of bleeding
Are periods painful? Y N
Length of periods
Birth control method
If you are menopausal / postmenopausal:
Age at menopause
Do you use hormones? Y N
How many years total?
Menopausal Symptoms: Hot flashes
Night sweats
Vaginal dryness
Insomnia
Mood changes
Supplements, Vitamins, OTC Medications:
Father: [ ] Living – Age:
Mother: [ ] Living – Age:
Siblings: Number Living:
[ ] Deceased, Age at Death:
[ ] Deceased, Age at Death:
Number Deceased:
Family History
(Cause)
(Cause)
(Cause)
List other illnesses in your family (Example – Diabetes, heart disease, colon cancer, breast cancer, osteoporosis, thyroid, etc.)
Who? (For example: brother, sister, aunt):
Problem:
Social History
# of packs/day
Smoke? [ ] Yes [ ] No If yes, how much?
# of years
Alcohol? [ ] Yes [ ] No If yes, how much?
Have you ever used recreational drugs? (i.e. marijuana, cocaine) If yes, what/when?
Domestic Violence?
Exercise regularly? [ ] Yes [ ] No
If yes, what and how frequently?
Routinely wear seatbelts? [ ] Yes [ ] No
Routinely wear a helmet? [ ] Yes [ ] No
(Over)
When did you stop smoking?
Use sunscreen? [ ] Yes [ ] No
Name ___________________________________
Review of Systems
Do you now or have you had any significant problems related to the following systems?
Circle Yes or No
Constitutional Symptoms
(Comments)
Weight change
Chills
Sleep Disorder
Other
Urinary
Y
Y
Y
N
N
N
Eyes
Double vision
Glaucoma
Cataracts
Other
Y
Y
Y
N
N
N
Ear/Nose/Throat/Mouth
Hearing changes
Sore throat
Sinus problems
Other
Y
Y
Y
N
N
N
Cardiovascular
Chest pain
Irregular heartbeat
Swelling in ankles
Other
Y
Y
Y
N
N
N
Psychologic
Are you generally happy?
Do you feel depressed?
Do you feel anxious?
Do you feel safe in your home?
Y
Y
Y
Y
Endocrine
Excessive thirst
Too hot/cold
Tired/sluggish
Other
Hematologic/lymphatic
Swollen glands
Blood clotting problem
Bruising
Other
Allergic/immunologic
Hay fever
Drug allergies
Food
Other
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Neurological
Tremors
Dizzy spells
Numbness/tingling
Other
Y
Y
Y
N
N
N
N
N
N
N
Respiratory
Wheezing
Frequent cough
Shortness of breath
Other
Y
Y
Y
N
N
N
Y
N
Gastrointestinal
Abdominal pain
Y
N
Y
Y
N
N
Nausea/vomiting
Indigestion/heartburn
Diarrhea/constipation
Y
Y
Y
N
N
N
Y
Y
Y
N
N
N
Sexual History
Are you sexually active?
Change in sex drive
Past S.T.D.?
Other (i.e. sexual trauma)
Y
Y
Y
N
N
N
N
N
N
Other Screenings
Normal result?
Date – Last Eye Exam: __________________________ Y
N
Date – Last Cholesterol Test:______________________ Y
N
Date – Last Dental Exam:_________________________ Y
N
Date – Last Thyroid Test: _________________________ Y N
Y
Y
Y
Change in stream
Nocturia (getting up at night)
Urinary frequency >8 times/day
Lose urine involuntarily
Current Medications
Musculoskeletal
Bone pain
Muscle pain
Joint pain
Any bone fracture after age 40?
Where?
Integumentary (skin)
Rash
Lumps or bumps
Moles, skin tags
Skin cancer
What is the reason for your current visit?
Physician/Nurse Practitioner use only
Signature
Date
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