Medical History Questionnaire
Name
*
First Name
Last Name
Birthdate
*
-
Day
-
Month
Year
Date
Sex:
*
Height:
*
Weight:
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred contact method:
*
Current Health Problems (list and include date of onset). If none, enter "N/A"
*
Do you have Past Medical History (list relevant information below)
Yes
No
Past Medical History
History of coronary artery disease (heart disease)
Stroke
History of seizures or epilepsy
History of heart murmurs/arrhythmia
Overactive or underactive thyroid
Anorexia or bulimia
Glaucoma
Substance abuse
Other
Past Medical History (list relevant information below with dates included). If none, enter "N/A"
Past Surgical History and Injuries (list below and include date). If none, enter "N/A"
*
Medication (list all prescriptions and include Name, Dosage, Frequency and Date Started). If none, enter "N/A"
*
Do you have any medication allergies? Please list. If none, enter "N/A"
*
How would you rate your health in general?
*
Please Select
Excellent
Good
Average
Fair
Poor
How many hours of sleep do you get each night (on average)?
*
Do you have any problems falling asleep?
*
Once asleep, do you have problems staying asleep?
*
Do you eat breakfast each morning?
*
Do you eat lunch each day?
*
On average, how much coffee do you consume daily? (please note the number of drinks/cups per day)
*
On average, how much tea do you consume daily? (please note the number of drinks/cups per day)
*
On average, how much soda/pop (ex Coke) do you consume daily? (please note the number of drinks/cups per day)
*
Are you a current smoker?
*
Please Select
Yes
No
If yes (you smoke), how much do you smoke? (if not applicable, enter "N/A")
Are you an ex-smoker?
*
Please Select
Yes
No
If yes (ex-smoker), when did you quit? (if not applicable, enter "N/A")
Do you use any illicit drugs?
*
If yes, which ones? (if not applicable, enter "N/A")
How much alcohol do you drink on average? (please provide # of drinks per day, # of drinks per week and # of drinks per month)
*
Have you ever had a problem with alcohol?
*
Do you manage stress well?
*
How do you manage stress? (check all that apply)
*
Exercise
Relaxation Techniques
Hobbies
Prayer / Spiritual activities
Family Relationships
Social Relationships
Other
Do you engage in regular physical activity?
*
Please Select
Yes
No
Submit
Should be Empty: