Health History Form
Full Name
*
First Name
Last Name
Gender
*
Male
Female
N/A
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Check any of the following conditions you have or have had in the past:
*
Asthma
Heart Disease
Diabetes
High Blood Pressure
Cancer
Psychiatric Disorder
Epilepsy
High Cholesterol
Thyroid Disease
Heart Attack
Enlarged Prostate
COPD/Emphysema
Kidney Disease
Arthritis
Rheumatoid Arthritis
Ulcers
Colon Polyps
Osteoporosis
Glaucoma
Stroke
Depression
Anxiety
Dementia
Liver Disease/Hepatitis
Congestive Heart Failure
Blood Clots
Migraines
Abnormal PAP Smear
Seizures
Lupus
No current or past conditions
List any other conditions or elaborate on checked boxes above (i.e. type of cancer):
List all surgeries you have had:
List all allergies and type of reaction:
List all medications (including vitamins and over-the-counter medications):
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Next
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
If you currently smoke, how many packs per day?
If you have a history of smoking, when did you quit?
Do you drink or do you have history of drinking alcohol?
*
Please Select
Yes
No
If yes, how much and how often?
Do you have a history of abusing drugs, alcohol, or prescription drugs?
*
Please Select
Yes
No
If yes, please explain:
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List conditions your family members have/had:
Mother:
Father:
Sisters:
Brothers:
Children:
Maternal Grandmother:
Maternal Grandfather:
Paternal Grandmother:
Paternal Grandfather:
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When and where was your last:
Mammogram
Pap Smear
Bone Density Test
Prostate Exam
Colonoscopy
Labs
Pneumonia Vaccine
Tetanus Vaccine
Whooping Cough Vaccine
Shingles Vaccine
Back
Next
List the names/specialties of other doctors you see (i.e. cardiologist, urologist, etc.):
Check any of the following you have had in the last month:
*
Fatigue
Weight Loss
Weight Gain
Frequent Fever
Loss of Appetite
Changes in Vision
Daily Headaches
Chest Pain
Shortness of Breath
Fluttering of Heart
Frequent Swelling
Frequent Dizziness
Passing Out
Persistent Heartburn
Persistent Reflux
Difficulty Swalling
Diarrhea
Constipation
Blood in Stool
Blood in Urine
Difficulty Urinating
Problems with Erection
Numbness/Tingling
Confusion
Memory Problems
Lumps on Skin
Changes in Moles
Persistent Depression
Persistent Anxiety
Frequent Illness
None of the above
Submit
Should be Empty: