IMMUHEALTHCARE Health Questionnaire

HEALTH QUESTIONNAIRE

Patient Name *

Date *

Date

Date of Birth: *

Date

Age *

Height *

Weight *

Chief Complaint or Concern #1. *

Chief Complaint or Concern #2.

Chief Complaint or Concern #3.

Type a question

Date of Onset and Description of Concerns:

Are problems?

Staying the same Worsening Improving

Can you? *

	Yes	No
Can you Wash, Bathe and Dress without assistance?
Can you sit through a movie?
Can you walk without assistance for over 30 minutes?
Can you get off the floor without your hands?
Can you lift a heavy bag of groceries without problems?
Can you carry a 10 pound bag 50 feet?
Can you do all your recreational & work activiies?

PRIOR WORKUP FOR PRESENTING PROBLEMS: Have you had?

	No	Yes	Month & Year	Findings
Labs
X-rays
MRI

RECENT TREATING DOCTORS

	Name of Doctor, City and State
Family Doctor
Doctor #1
Doctor #2

PAST MEDICAL HISTORY: *

	Yes	No
Seizures
Stroke
Glaucoma
Thyroid Disease
Diabetes
Hypertension
High Cholesterol
Heart disease or Irregular Rhythm
COPD or Emphysema
Asthma
GERD or Reflux Gastritis
Pancreatitis
Hepatitis
Kidney problems
Prostate enlarged, prostatitis
Pelvic/Genital problems
Arthritis
Chronic Pain
Chronic Infection
Cancer
Addiction
Depression
Anxiety
ADHD

Have you had any PAST SURGERIES? *

Yes No

LIST ANT PAST SURGERIES:

	Month & Year	Operation Performed	Did it help?
Operation #1
Operation #2
Operation #3
Operation #4

FAMILY HISTORY: Does any family members suffer from:

	Mother	Father	Siblings	Children
Thyroid problems
Diabetes
High blood pressure
Heart disease
Stroke
Arthritis
Autoimmune Disease
Cancer
Addiction
Depression/Psych

Type a question *

	Yes	No
Are you married or live with a person?
Do you live with other people?
Do you smoke cigarettes?
Do you drink alcohol daily?
Do you use any street drugs?

Do you have any DRUG ALLERGIES? *

Yes No

LIST ALL ALLERGIES TO DRUGS OR ANESTHESIA:

	Drug Name	Reaction (Rash, Swelling, shortness of breathe)
Drug #1
Drug #2
Drug #3

Are you taking any MEDICATIONS or Over-the-counter Supplements/Herbs? *

Yes No

LIST THE MEDICATIONS or Over-the-counter Supplements:

	Medication	Strength	Frequency	For What Condition	Prescribing Physician
Drug #1
Drug #2
Drug #3
Drug #4
Drug #5
Drug #6
Drug #7
Drug #8

Have you tried any medications previously for your problems? *

Yes No

List PAST DRUGS attempted for your problem:

	Medication	Strength	Did it help?	Why did you stop?
Drug #1
Drug #2
Drug #3
Drug #4

REVIEW OF SYSTEMS (General Health Questions): Do you have any problems with *

	Yes	No
Fever. Chills. Swelling.
Sleep less than 6 hours.
Headaches. Migraines.
Difficulties in Vision.
Difficulties in Hearing.
Nasal or sinus congestion. Nose bleeds. Unable to smell or taste.
Problems with teeth or gums. Sore throat. Swollen glands.
Chest pain. Rapid or irregular heart beats. Feet swelling.
Shortness of Breath.
Wheezing. Coughing.
Nausea. Vomiting.
Heartburn. Abdominal pain.
Yellow jaundice.
Diarrhea. Constipation.
Bright red blood in stool. Dark stool.
Poor libido.
Pelvic pain.
Sexual Dysfunction (ED in men. FSD in women.)
Frequent urination. Burning. Urgency. Weak urine flow.
Wake up to urinate.
Weakness. Fatigue.
Joint pain. Muscle pain.
Problems with Balance.
Skin rashes. Acne. Moles. Easing bruising.
Hair loss.
Numbness. Tingling.
Seizures.
Forgetful.
Repeatedly or overly worried. Rapid thoughts.
Trouble falling asleep.
Snoring.
Feeling sad or depressed.
Feeling hopeless. Suicidal thoughts.
Weight Loss. Poor Appetite.
Weight Gain. Excessive Appetite.

Signature *

Clear

Date *

Date