Medical History Questionnaire
Please complete all applicable sections of this medical history form. All fields are optional unless specifically marked as required on the original PDF. Keep field labels close to the original wording.
Client & Contact Information
Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Name
Address
Contact phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Client Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Family Physician / Primary Health Care Provider: Doctor Name
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Marital Status
Single
Married
Divorced
Widowed
Sex
Male
Female
Present Medical History
Has a doctor ever said your blood pressure was too high?
Yes
No
Do you ever have pain in your chest or heart?
Yes
No
Are you often bothered by a thumping of the heart?
Yes
No
Does your heart often race?
Yes
No
Do you ever notice extra heartbeats or skipped beats?
Yes
No
Are your ankles often badly swollen?
Yes
No
Do cold hands or feet trouble you even in hot weather?
Yes
No
Has a doctor ever said that you have or have had heart trouble, an abnormal ECG/EKG, heart attack or coronary?
Yes
No
Do you suffer from frequent cramps in your legs?
Yes
No
Do you often have difficulty breathing?
Yes
No
Do you get out of breath long before anyone else?
Yes
No
Do you sometimes get out of breath when sitting still or sleeping?
Yes
No
Has a doctor ever told you your cholesterol level was high?
Yes
No
Has a doctor ever told you that you have an abdominal aortic aneurysm?
Yes
No
Has a doctor ever told you that you have critical aortic stenosis?
Yes
No
Recent/Current Symptoms
Chronic, recurrent, or morning cough
Yes
No
Episode of coughing up blood
Yes
No
Increased anxiety or depression
Yes
No
Problems with recurrent fatigue, trouble sleeping, or increased irritability
Yes
No
Migraine or recurrent headaches
Yes
No
Swollen or painful knees or ankles
Yes
No
Swollen, stiff, or painful joints
Yes
No
Pain in your legs after walking short distances
Yes
No
Foot problems
Yes
No
Back problems
Yes
No
Stomach or intestinal problems (heartburn, ulcers, constipation, diarrhea)
Yes
No
Significant vision or hearing problems
Yes
No
Recent change in a wart or a mole
Yes
No
Glaucoma or increased pressure in the eyes
Yes
No
Exposure to loud noises for long periods
Yes
No
An infection such as pneumonia accompanied by a fever
Yes
No
Significant unexplained weight loss
Yes
No
A fever, which can cause dehydration and rapid heartbeat
Yes
No
Deep vein thrombosis (blood clot)
Yes
No
A hernia that is causing symptoms
Yes
No
Foot or ankle sores that won't heal
Yes
No
Persistent pain or problems walking after you have fallen
Yes
No
Eye conditions such as bleeding in the retina or detached retina
Yes
No
Cataract or lens transplant
Yes
No
Laser treatment or other eye surgery
Yes
No
Women Only
Menstrual period problems
*
Yes
No
Significant childbirth-related problems
*
Yes
No
Urine loss when you cough, sneeze, or laugh
*
Yes
No
Hormones & Medications
Are you on any type of hormone replacement therapy?
*
Yes
No
List prescription medications and frequency
List self-prescribed medications or dietary supplements
Recent Tests & Exams
Medical or diagnostic tests in past two years (dates and reasons)
Hospitalizations & Allergies
Hospitalizations (dates and reasons)
Drug allergies
Past Medical History
Past medical conditions
Heart attack
Rheumatic Fever
Heart murmur
Diseases of the arteries
Varicose veins
High blood pressure
High cholesterol
Stroke
Blood clot
Lung disease
Asthma
Pneumonia
Tuberculosis
Kidney disease
Liver disease
Diabetes
Thyroid disease
Cancer
Depression
Anxiety
Heart attack – how many years ago?
Family Medical History
Which family medical history conditions apply?
Heart attacks under age 50
Strokes under age 50
High blood pressure
Elevated cholesterol
Diabetes
Heart disease
Cancer
Asthma
Stroke
Kidney disease
Thyroid disease
Mental illness
Other
Additional Information
Immediate family affected?
Mother
Father
Sibling
Child
Grandparent
Aunt
Uncle
Other
Condition onset in family members
Under 30
30–39
40–49
50–59
60 or older
Unknown
Which family members have a history of heart disease?
Mother
Father
Sibling
Child
Grandparent
Aunt
Uncle
Other
Which family members have a history of cancer?
Mother
Father
Sibling
Child
Grandparent
Aunt
Uncle
Other
Which family members have a history of diabetes?
Mother
Father
Sibling
Child
Grandparent
Aunt
Uncle
Other
Lifestyle – Smoking
Ever smoked cigarettes, cigars, or a pipe?
*
Yes
No
Cigarettes per day
Cigarettes – Age started
Cigars per day
Cigars – Age started
Pipefuls per day
Pipe – Age started
If stopped smoking, when
Diet & Nutrition
Number of meals per day
Additional Information About Diet & Food allergies
Certification / Acknowledgment
Print Name (Client/Representative)
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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