Health History Questionnaire

Health History Questionnaire

Please be as honest as possible.
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Age
Marital Status

SingleMarriedSeparatedDivorcedWidowed
Gender

MaleFemale
Social / Work History
Current Occupation Status

EmployedUnemployedLOAOther
Occupation or Last Occupation
Please describe the way you want your event to be.
Are you taking any medications?

YesNo
List your medications

Only Answer for yourself

Rows	Type	Current	Past	Comment
Alcoholism/Drug Abuse
Asthma
Cancer
Depression/Anxiety/Bipolar/Suicidal
Diabetes
Emphysema (COPD)
Heart Disease
High Blood Pressure (hypertension)
High Cholesterol
Hypothyroidism/Thyroid Disease
Renal (kidney) Disease
Migraine Headaches
Stroke
Other:
Other:

Please indicate the major surgeries that you had (if any)

Rows	Details
Date of Last Menstrual Cycle:
Age of First Menstruation:
Age of Menopause:
Total Number of Pregnancies:
Number of Live Births:
Pregnancy Complications:

Family Medical History

Rows	Mother	Father	Child	Maternal GM	Maternal GF	Paternal GM	Paternal GF
Alcohol/Drug Abuse
Asthma
Emphysema (COPD)
Depression / Anxiety
Bipolar / Suicidal
Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Migraines

Please Indicate which among your direct relatives has or had cancer
Do you smoke on a regular?

YesNo
How many times per day
How long have you been smoking?
Do you use any other recreational drugs?

YesNo
Do you drink alcohol?

YesNo
Review of Current Systems
Constitution

Activity changeAppetite changeChillsDiaphoresisFatigueFeverUnexpected weight change
Eyes

Blurry vision/Double visionCataracts/ Macular degenerationGlasses/Contacts/BlindnessGlaucoma/RetinopathyPartial loss of vision/blind spots
Ears/Nose/Mouth/Throat

Dentures/Difficulty swallowingHearing Loss/ringing in earsProlonged Nose bleedsVoice change
Cardiovascular

Ankle Swelling /VaricositiesCalf pain with/without exerciseChest pain with exertion/ExerciseChest pain/ Heart murmurDyspnea on exertion/SyncopeIrregular/Rapid heart rateLeg Pain/Cramping in legs at night
Respiratory

Asthma/ Anesthetic problemsCOPD/Pneumonia/EmphysemaCoughing/coughing up bloodHoarsness/Obstructive Sleep ApneaOxygen Dependent LPMShortness of Breath with ExertionShortness of breath /WheezingTuberculosis or exposure
Gastrointestinal

Abdominal pain/Blood in stoolBlack or Tarry stoolBloating/Diarrhea/ConstipationLoss of appetite/HeartburnNausea/VomitingUlcer disease/Pain after eatingVomited blood
Endocrine

Cold/Heat intoleranceHistory of drug resistant infection
Integumentary (Skin)

New skin lesions/Skin CancerRash/Persistent itchingUnhealed/Delayed healing of sores
Neurological

Migraines/Headache/VertigoTemporary/Paralysis Arm/Leg/FaceTingling/NumbnessSpeech difficulties/Seizures
Musculoskeletal

Artificial knee or hip jointBack pain/Joint painDegenerative/OsteoarthritisMuscle pain/Weakness/CrampsRheumatoid Arthritis
Genitourinary

ImpotenceIncontinence /Difficulty VoidingKidney stonesSuprapubic/Indwelling CatheterUrgency/Blood in Urine
Psychiatric

Anxiety/DepressionConfusion/Memory lossDifficulty sleeping
Heme/Lymphatic/Immune

Anemia/Low platelet countBleeding disorder/Easy bleedingEasy bruisingLymphoma/LeukemiaFrequent illnesses
Do you want a consultation to go over how Cannabis can help your medical issues.

YesNo

Health History Questionnaire

THC and CBD Usage