HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire arestrictly confidential and will become part of your medical record.
Name
*
First Name
Last Name
DOB
*
Marital Status
Single
Partnered
Married
Separated
Divorced
Widowed
Previous or referring doctor
Date of last exam
/
Month
/
Day
Year
Date
Specialists name and location (cardiologist, dermatologist, etc...)
Tobacco Use:
Yes
No
Alcohol Use:
Yes
No
PERSONAL HEALTH HISTORY
Childhood illness
Measles
Mumps
Rubella
Chickenpox
Rheumatic Fever
Polio
Immunizations:
Tetanus/Tdap
COVID
Hepatitis
Influenza
Pneumonia
COVID Booster
Chickenpox
MMR Measles,Mumps, Rubella
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Have you ever been told by a Medical Doctor that you have any of the following conditions?
Rows
Yes
No
N/A
Congenital heart disease
Heart Attack / Myocardial Infarction
Hypertension/High Blood Pressure
Diabetes Mellitus/Sugar (Type 2)
Glaucoma
Kidney Disease
Diabetes: Type 1
High Cholesterol
Depression/Anxiety
Transient Ischemic Attack (TIA)
Coagulation Disorders/Bleeding Problems
Alcohol Abuse
Thyroid Disease
Hay fever
Lupus
Epilepsy/Seizures
Environmental Allergies
Sexually transmitted Disease
Women-Abnormal Pap Smear
Urinary Incontinence
Birth Defects
Hearing Problems
Osteoporosis
Asthma
Rheumatoid Arthritis
BPH
Skin Cancer
Breast Cancer
Prostate Cancer
Ovarian Cancer
Cancer, other
Migraines/Headaches
Mental Disability
Arthritis
Anemia or Blood Disorder
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List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers.
Rows
Drug Name
Strength
Frequency Taken
1.
2.
3.
4.
5.
6.
7.
Allergies to medications
Rows
Drug Name
Reaction you had
1.
2.
3.
4.
FAMILY HEALTH HISTORY
Rows
Age
Significant Health Problems
Mother
Father
Grandmother (Maternal)
Grandfather (Maternal)
Grandmother (Paternal)
Grandfather (Paternal)
Rows
Sex Assigned at Birth
Age
Significant Health Problems
Sibling
Sibling
Sibling
Sibling
Sibling
Children
Children
Children
Children
Children
Patients Name Printed
*
Date
*
/
Month
/
Day
Year
Date
Patients Signature
*
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