Health History
How would you describe your overall general health? (Please circle one. Add comments
if you want.)
Excellent
Good
Fair
Poor
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As a child and teenager, what were your major health problems?
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Medications:
What medications are you currently taking?
Medication
How much? How
taken?
How often? What for?
Allergies/adverse reactions:
Are there any medications that have caused you problems?
Medication
Reason you can’t take this medication
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Are you allergic to foods or other things (such as bee stings, pollen, cats, etc)?
Food or substance
Reaction and treatment
Immunizations:
Please list your immunization dates or attach a copy of your immunization record.
DPT/DT
1.
2.
3.
4.
5.
TDaP
1.
2.
3.
4.
5.
Polio
1.
2.
3.
4.
5.
HIB
1.
2.
3.
4.
5.
MMR
1.
2.
Hep B
1.
2.
3.
Hep A
1.
2..
Varicella
1.
2.
Meningitis
1.
Pneumonia 1.
2.
HPV
1.
2.
3.
Do you get yearly flu vaccines? ______________________________________
Past medical history:
What was your birth weight? ________ Length?_________
Were you born early?_______ If so, how early? _________
Did you mother have any problems with her pregnancy or delivery of you?
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Were you hospitalized at birth? ______ For how long? __________
What problems did you have at birth?
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Please list any serious illnesses or injuries that you have had
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List any hospital stays and surgeries you have had. Include the dates and places where
they occurred.
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Have YOU ever had the following? Check the problem and list the age you were
diagnosed.
Condition
Yes
Age
Condition
Yes
Age
anemia
growth problems
asthma
kidney problems
blood transfusion
tuberculosis
cancer
ADD/ADHD
constipation
learning disability
diabetes
anxiety
ear infections
depression
heart disease
conduct disorder
high cholesterol
bipolar disorder
high blood
eating disorder
pressure
thyroid disease
suicide attempt
celiac disease
Other conditions
seizures
hepatitis
If you answered yes to any of the above conditions, please use this space to make any
additional comments about your condition.
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Activities of Daily Living
Yes
Do you have trouble seeing?
Do you wear contacts or glasses?
Are you deaf or hard of hearing?
Do you use hearing aids?
Do you have speech problems?
Do you use sign language?
Is English your preferred language?
If no, what language do you speak?
Do you routinely wear medic alert identification?
Do you drive?
If you have diabetes, do you check your blood
sugar before driving?
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No
Social History:
Are you a student? ________ If yes, where and what year? _________________
Are you employed? _______ If yes, where and what is your job?
________________________________________________________________
How many hours a week do you work? _________________________________
Are you involved in any regular physical activity? _______ If yes, what?
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Do you have friends and a good support system?
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[The next few questions may be asked in private. You may write the answers if you
choose to do so.]
Do you smoke cigarettes or chew tobacco? __________________________________
If yes, when did you start? ________________________________________________
How much and how often do you use tobacco? _______________________________
Do you drink alcohol? ________. If yes, how much and what kind? _______________
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Do you drink to get drunk? _____ If yes, how often? ____________________________
Do you smoke marijuana or use other drugs? _____ What kind? __________________
Are you now or have you ever been sexually active? _______ If yes, do you use birth
control? ________ What kind? ____________________________________________
Do you use condoms? _________ Do you use them every time you have sexual
contact? _________________________________________________________
Family Health History
Have any of your blood relatives had any of the following?
Condition
Relation
Condition
anemia
ADD/ADHD
breast cancer
alcoholism
cancer (other
depression
types)
diabetes
drug abuse
heart attack
learning disability
high cholesterol
bipolar disorder
high blood
suicide
pressure
seizures
schizophrenia
stroke
Other conditions
thyroid problems
tuberculosis
© Children's Hospital of Wisconsin. All rights reserved
relation
Comments:
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Recent medical records:
Please list the name, address, and telephone number of any doctors or other health
care providers who have the latest medical records about your health problems:
Name
Specialty
Address
Telephone
Emergency Contacts:
Name
Relationship
(W)
(W)
(W)
(W)
Telephone numbers
(H)
(H)
(H)
(H)
Insurance information:
Insurance
Policy number
Telephone number
Preferred pharmacy
Name
Location
Telephone number
Endocrinology/Diabetes 2013
© Children's Hospital of Wisconsin. All rights reserved
© Children's Hospital of Wisconsin. All rights reserved
