Health History

PATIENT HEALTH HISTORY FORM

NEVERPASTCURRENT - How many Packs per day? For how many years total?

NEVERPASTCURRENT - Substance(s) used? How much and frequency? For how many years total?

NONE1-2 per day3 or more per day

1-2 per day3 -5 per dayOther

ALWAYSNEVERSOMETIMES

YESNOIF YES, PLEASE EXPLAIN

YESNOIF YES, HOW MUCH CHANGE?

SURGICAL HISTORY

*CURRENT* MEDICAL CONDITIONS

*PAST* MEDICAL HISTORY

REVIEW OF SYSTEMS

(CHECK BOX IF RECENTLY or CURRENTLY EXPERIENCING)

persistent coughcoughing up bloodasthma or wheezingshortness of breath

excess thirstcold or heat intolerancegoitergout

change in urine streamnightly awakenings to urinatesexual function concerns

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