allenaim.com - Health History Questionnaire

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.
Main reason for today's visit:
Other concerns:
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:

(WOMEN ONLY) OBSETRIC AND GYNECOLOGICAL HISTORY
Last PAP Smear: Date

MonthDayYear
Date
Abnormal
Last Mammogram: Date

MonthDayYear
Date
Abnormal
Age of first menstrual period
Date of last menstrual period or age of menopause:
Number of pregnancies:
Births:
Miscarriages:
Abortions:
Cesarean sections
If yes, then number:
Check all that apply

Bleeding between periodsHeavy periodsExtreme menstrual painVaginal itching, burning, or dischargeWake in the night to go to the bathroomHot flashesBreast lump or nipple dischargePainful intercourseSexually active
Current sexual partner is

FemaleMale
Do you use condoms

YesNo
Other Birth control method used:
Interested in being screened for STD's

HEALTH HISTORY QUESTIONNAIRE