• HEALTH HISTORY QUESTIONNAIRE

  • Your answers on this form will help your health care provider better understand your medical concerns and conditions. If you are uncomfortable with any question, do not answer it. If you cannot remember specific details, please approximate. Add any notes you think are important. ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.

  • ALLERGIES

  • List anything that you are allergic to (medications, food, bee stings, etc.) and how each affects you.

  • FAVORITE PHARMACY

    MEDICATIONS
  • Please list all the medications you are taking. Include prescribed drugs and over-the-counter drugs, such as vitamins and inhalers.

  • IMMUNIZATION HISTORY

  • Immunization and most recent date:
    Rows

  • (WOMEN ONLY) OBSETRIC AND GYNECOLOGICAL HISTORY

  • Last PAP Smear: Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last Mammogram: Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Check all that apply
  • Current sexual partner is
  • Do you use condoms

  • PAST MEDICAL HISTORY

  • Please check all that apply

  • PAST SURGICAL HISTORY

  • FAMILY HEALTH HISTORY

  • Alive:
  • Significant Health Problems:
  • Alive:
  • Significant Health Problems:
  • Alive:
  • Significant Health Problems:
  • Alive:
  • Significant Health Problems:
  • Alive:
  • Significant Health Problems:
  • Alive:
  • Significant Health Problems:
  • Alive:
  • Significant Health Problems:
  • Alive:
  • Significant Health Problems:

  • SOCIAL HISTORY

  • Education
  • Caffeine
  • If not currently, did you ever use tobacco?
  • Marital Status
  • Alcohol: Do you drink alcohol?
  • If so, how often?
  • Drugs: Do you currently use recreational or street drugs?
  • Exercise Level:
  • Tobacco: Do you use tobacco?

  • REVIEW OF SYSTEMS

    Please check all that apply
  • Allergic/ Immunologic:
  • Cardiovascular:
  • Constitutional:
  • Eyes
  • Date of Last Exam:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Ears/Nose/Mouth/Throat
  • Endocrine
  • Gastrointestinal
  • Genitourinary
  • Hematologic/Lymphatic
  • Integumentary (Skin)
  • Musculoskeletal
  • Neurological
  • Psychiatric
  • Respiratory
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: