FAMILY TREE CLINIC HEALTH HISTORY FORM

Health History Form
Preferred name:
Gender pronouns*
Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age:*
Gender Identity:*
Sex assigned at birth*

FemaleMale
Occupation:
Allergies:
Reaction(s):
Medications (including over the counter medications, birth control methods, herbs, supplements and vitamins):
Medication:
Dosage:
Medication:
Dosage:
Medication:
Dosage:
Medication:
Dosage:
Medication:
Dosage:
Medication:
Dosage:
PERSONAL MEDICAL HISTORY
Check if you have had any of the following:

AnemiaAnxietyHypertension high blood pressureArthritisAsthmaBlood clots or disordersCancerCoronary artery disease(heart disease or heart attack)DepressionDiabetesElevated (high) cholesterolGallbladder diseaseGERD (reflux/heartburn)Headache, migrainesHepatitis/Liver DiseaseIrritable bowel diseaseOsteoporosisRenal (kidney) diseaseSeizure disorderStrokeThyroid diseaseBreast lumpEating disorderChemical dependencyUrinary tract/bladder infection (UTI)
Other - please list:
Have you ever had surgery?

YesNo
Have you ever had surgery?*

YesNo
If yes, please explain:
Have you ever been hospitalized?

YesNo
Have you ever been hospitalized?*

YesNo
If yes, please explain:
GENERAL HEALTH
Do you smoke or use tobacco?

YesNo
Do you smoke or use tobacco?*

YesNo
If yes, how much per day?
Are you interested in quitting?

YesNo
Do you use e-cigarettes/vaping?

YesNo
Do you drink alcohol?

YesNo
Do you drink alcohol?*

YesNo
If yes, how many drinks per week?
Do you use recreational/street drugs?

YesNo
If yes, how often per week?
Have you ever used needles to take drugs?

YesNo
Have you ever used needles to take drugs?

YesNo
If yes, do you share needles?

YesNo
How often do you exercise?
Are you being or have you been sexually or physically mistreated?

YesNo
Do you want to talk about it?

YesNo

Did you receive the following immunizations/vaccines:*

	Yes	No
Hepatitis B
HPV (Gardasil)
Tdap (Tetanus/diptheria/pertussis)

Is there anything else you would like us to know about you or your health?
FAMILY MEDICAL HISTORY
If you are adopted check hereIf you do not know any biological family medical history check here

Mark for any relatives with the following

	Mother	Father	Brother	Sister	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather
Blood Disease/Blood Clots
Cancer
Cardiovascular (heart) Disease
Diabetes
Genetic Disease
Hypertension (high blood pressure)
Osteoporosis
Stroke
Thyroid Disease

Other (please list)
Sexual Health and Family Planning
Do you or your partner(s) want to be pregnant?

NowIn the futureNeverUnsure
Are you or your partner(s) currently using a method of birth control?

YesNo
If yes, what method?
How long have you used this method?
Any problems with this method?
Check which methods of Birth Control you have ever used:

Birth Control PillsThe PatchVaginal Ring (Nuva Ring)SpermicideDepo (The Shot)DiaphragmNorplantImplanon/NexplanonIUDTubal ligationCondomsCervical capFertility awarenessCycle beadsWithdrawal (Pull-out)Vasectomy
Check any of the following you currently have, or have had in the past:

ChlamydiaGonorrheaHerpesHIVGenital Warts/HPVHepatitis B or CSyphilisPelvic Inflammatory Disease (PID)TrichomonasOther
Have you ever been sexually active?*

YesNo
Are you currently sexually active?*

YesNo
What are the gender(s) of your sexual partner(s)?
How many people have you had sex with in the past 3 months?*
How many people have you had sex with in the past 12 months?*
What types of sexual activities do you practice?

VaginalOralAnalTouch with handsSex toys
What do you do to prevent sexually transmitted infections (STIs)?
What do you do to prevent sexually transmitted infections (STIs)?*

0/100
GYNECOLOGICAL AND BREAST HISTORY
Have you ever had a Pap smear?*

YesNo
When was your last Pap smear?
Have you ever had an abnormal Pap?*

YesNo
If yes, please explain:
MENSTRUAL CYCLE
When did your last period start?
Was it normal?
Periods come every ________ days
fill in the blank
and last _________ days
fill in the blank
Periods are usually

lightmoderateheavycrampyirregular
Age periods started
PREGNANCY HISTORY
Are you pregnant now?*

YesNoUnsure
Have you ever been pregnant?*

YesNo
How many times?
# of live births
date(s)

MonthDayYear
Date
# of abortions
date(s)

MonthDayYear
Date
# of miscarriages,
date(s)

MonthDayYear
Date
# of ectopic
date(s)

MonthDayYear
Date
Any problems with pregnancy or birth?

YesNo
If yes, please explain
Diabetes in pregnancy?

YesNo
For Ages 40 and Over
Have you ever had a mammogram?

YesNo
Was it normal?

YesNo
If no, please explain:
Check if you have had any of the following:

Hot flashesTrouble sleepingNight sweatsRapid mood changesVaginal drynessLibido problemsUrine leakingOther
Family Tree Clinic ● 1919 Nicollet Ave, Minneapolis, MN 55403 ● 612.473.0800
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Health History Form