Health History Questionnaire

Health History Questionnaire
General Information
Patient Gender*
Patient Birth Date*

MonthDayYear
Patient Name*

First NameLast Name
Patient Height (cm)*
Patient Weight (kg)*
Patient E-Mail*
example@example.com
Reason for seeing the doctor:*
ex: Routine Check-up
Medical History
Please list if you have any drug allergies
ex: Penicilin
Have you ever had (Please check all that apply)

AnemiaAsthmaCancerDiabetesEpilepsy SeizuresGallstonesHeart DiseaseHeart AttackHigh Blood PressureUlcer DiseaseHepatitisSleep ApneaThyroid ProblemsTuberculosis
Please list if you have other illnesses:
Please list any operations and dates of each:
Please list your current medications
Healthy & Unhealthy Habits
Exercise

Never1-2 days3-4 days5+ days
Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Add other comments regarding your medical history.
Should be Empty:

Healthy & Unhealthy Habits