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HEALTH HISTORY QUESTIONNAIRE
Date:_____________________________________ All questions contained in this questionnaire are strictly confidential and will become part of your medical records Name: (Last, First, M.I.) M F DOB:
Marital status: Single Partnered Married Separated Divorced Widowed
Primary Care Physicians: Referring Physicians:
PLEASE DESCRIBE THE REASON FOR YOUR VISIT TODAY
PLEASE LIST YOUR MEDICATIONS AND DOSAGES (Please attach additional sheet if necessary)
Medication Name
Strength (MG)
Times per day
Referring Physician
ALLERGIES TO MEDICATIONS None
Name of Drug
Reaction You Had
Are you allergic or sensitive to LATEX? Yes No
PAST MEDICAL HISTORY (Please check all that apply)
Presently pregnant
Use Coumadin
Irritable bowel syndrome Prostate enlarged Use Plavix
Use aspirin
Use other anticoagulant
Health History Questionnaire
Name: ________________________________________ PAST SURGICAL HISTORY (Please check all that apply)
Family History of (Please select all that apply)
None Unknown
Please indicate, next to the condition, the family member who has or had the disease using the abbreviations below:
M=Mother, F=Father, S-Sister, B=Brother, MGF=Maternal Grandfather, PGF=Paternal Grandfather, MGM=Maternal Grandmother
PGM=Paternal Grandmother, PU=Paternal Uncle, MU=Maternal Uncle, PA=Paternal Aunt, MA=Maternal Aunt
Other ______________________________________________________ Social History (Please check each column)
Marital Status:
Employment status: Tobacco (choose one)
Do you drink alcohol?
Amount____ pks/day _______________________ Amount____ #/week # drinks per day? ________ Former smoker: Year quit ______ Never smoker Health History Questionnaire
Name: _________________________________________ Date:________________________________________ Height and Weight
Please check off all that apply for each body system
General complaints of:
Nervous System
Breathing
Hematologic
Shortness of Breath in general Bleed Easily Gastrointestinal
Psychological
Genitourinary
Change in Bowel Habit Difficulty Swallowing Yellow eyes or skin Health History Questionnaire
Name: _________________________________________ Date:_____________________________________ Please check off all that apply for each body system
Vascular
Muscular/Skeletal
Endocrine
Women only
Age at onset of menstruation: ___________________________ Date of last menstruation:___________________________ Have you ever taken birth control pills or hormone therapy? If yes, for how long? _____________________ Please list any physicians to whom you would like a report of your treatment sent: (write name of physician)
Gastroenterologist:
Cardiologist:
Dermatologist:

Source: http://advancedsurgery.net/downloads/3%20medical%20history.pdf