NORTH TEXAS DIABETES AND ENOCRINOLOGY
190 CIVIC CIRCLE DR. SUITE 272
LEWISVILLE, TEXAS 75067
214-222-2700
214-222-2705 (Fax)
MEDICAL HISTORY QUESTIONNAIRE
DATE: ____/_____/____
NAME: ________________________________________________________________
AGE: ______
HEIGHT:_______
WT:________
INITIAL HISTORY
1. WHY ARE YOU COMING TO THE DOCTOR? ____________________________
______________________________________________________________________
2. HAVE YOU EVER HAD ANY OF THE FOLLOWING (Please check)?
○ DIABETES
○ HIGH BLOOD PRESSURE
○ HIGH CHOLESTEROL
○ HEART ATTACK
○ ANGINA
○ STROKE / MINI STROKE (Please circle)
○ ASTHMA / ALLERGIES (Please circle)
○ LUNG DISEASE
○ CANCER (specify:_________________)
○ GOUT
○ THYROID PROBLEMS
○ OTHERS________________________
3. LIST ANY SURGERIES THAT YOU HAVE HAD:
SURGERY: ___________________________
YEAR: __________________
SURGERY: ___________________________
YEAR: __________________
SURGERY: ___________________________
YEAR: __________________
4. LIST ANY PAST HOSPITALIZATIONS:
WHEN:___________________________
WHY: ________________________
WHEN: ___________________________ WHY:________________________
5. WHAT MEDICATIONS ARE YOU TAKING (If Diabetic, see Diabetes Questionnaire)?
MEDICATION_______________________
MEDICATION ________________________
MEDICATION _______________________
MEDICATION ________________________
MEDICATION _______________________
MEDICATION ________________________
MEDICATION ________________________
MEDICATION ________________________
MEDICATION ________________________
MEDICATION ________________________
MEDICATION ________________________
DOSE________________________
DOSE________________________
DOSE ________________________
DOSE________________________
DOSE ________________________
DOSE________________________
DOSE________________________
DOSE________________________
DOSE________________________
DOSE________________________
DOSE________________________
1
6. ARE YOU ALLERGIC TO ANY MEDICATIONS?
YES
NO
IF YES, WHICH ONES? _____________________________________________
_________________________________________________________________
7.
FAMILY HISTORY:
A) DO YOU HAVE FAMILY MEMBERS WITH DIABETES? YES NO
IF YES, WHO HAS DIABETES?
_________________________________
B) DO YOU HAVE FAMILY MEMBERS WITH A THYROID PROBLEM?
YES NO
IF YES, WHO HAS THYROID PROBLEM?_______________________
C) PLEASE CHECK IF BLOOD RELATED MEMBERS OF YOUR FAMILY HAVE HAD
ANY OF THE FOLLOWING:
_____ HEART DISEASE
_____ KIDNEY DISEASE
_____ OBESITY
_____STROKE
_____ CANCER
_____ HIGH BLOOD PRESSURE
_____ HORMONE PROBLEMS _____ HIGH CHOLESTEROL
8.
IMMUNIZATION:
WHEN
FLU SHOT
PNEUMO VACC
9.
______________
______________
SOCIAL HISTORY:
MARITAL STATUS: Single
Married Divorced Separated Widowed
DO YOU SMOKE CIGARETTES?________ HOW MANY PACKS /DAY?_____
DO YOU DRINK ALCOHOL?________HOW MANY PER DAY/WEEK?_________
EDUCATION COMPLETED: GRADE SCHOOL____ HIGH SCHOOL___ COLLEGE_______
10. CURRENT SYMPTOMS (Review of Systems):
General:
Weight Gain
Weight Loss
Weakness
Fatigue
YES
YES
YES
YES
OR
OR
OR
OR
NO (How much? ________________)
NO (How much? ________________)
NO
NO
Skin:
Hair Loss
Itching
Dryness
YES OR NO
YES OR NO
YES OR NO
Eyes, Ear, Nose & Throat:
Blurred vision (recent)
Cataract
Laser Treatment (not LASIK)
YES OR NO
YES OR NO
YES OR NO (when? __________________)
Chest:
Cough
Shortness of breath
YES OR NO
YES OR NO
Cardiovascular:
Chest pain
Palpitations
Shortness of breath with exertion
Shortness of breath while lying flat
YES OR
YES OR
YES OR
YES OR
NO
NO
NO
NO
2
Swelling of the legs/ ankles
Painful legs while walking
Foot ulcers
YES OR NO
YES OR NO
YES OR NO
Gastrointestinal:
Loss of appetite
Excessive hunger
Heartburn
Nausea
Abdominal pain
Constipation
Loose bowel movements (diarrhea)
YES OR
YES OR
YES OR
YES OR
YES OR
YES OR
YES OR
NO
NO
NO
NO
NO
NO
NO
Urinary:
Frequent urination
Problem starting stream
Incontinence
YES OR NO
YES OR NO
YES OR NO
Genital:
Libido (desire)
Men:
Erection problems
Women:
Regular periods
No. of pregnancies: ___________
Menopause
If yes: natural or surgical
Age, periods started: ___________
Last menstrual period: __________
Normal or Low
YES OR NO
YES OR NO
YES OR NO (age at menopause:___________)
Musculoskeletal:
Arthritis
YES OR NO
If yes: what joints bother you the most: __________________
Tendonitis/ Bursitis
YES OR NO
Back or neck pain
YES OR NO
Neurological:
Frequent headaches
Burning sensation in the feet & hands
Numbness in the feet & hands
Depressed
Mood swings
YES OR
YES OR
YES OR
YES OR
YES OR
NO
NO
NO
NO
NO
If you are seeing Dr. Haque for Diabetes, please fill out the Diabetes 1st visit Questionnaire as well.
____________________
Patient Signature
___________
Date
________________________________
Wasim A. Haque, M.D. (Reviewed with the patient)
___________
Date
3