• HEALTH HISTORY QUESTIONNAIRE

    All questions contained in this questionnaire arestrictly confidential and will become part of your medical record.
  • Marital Status
  • Date of last exam
     / /
    2 digit month, 2 digit day, 4 digit year
  • Tobacco Use:
  • Alcohol Use:

  • PERSONAL HEALTH HISTORY

  • Childhood illness
  • Immunizations:
  • Have you ever been told by a Medical Doctor that you have any of the following conditions?
    Rows
  • List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers.
    Rows
  • Allergies to medications
    Rows

  • FAMILY HEALTH HISTORY

  • Rows
  • Rows
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: