Patient S History and Health Questionnaire

PATIENT’S HISTORY AND HEALTH QUESTIONNAIRE

NAME:D.O.B.DATE

PLEASE LIST ANY CONDITION OR DISEASE WHICH YOU WISH TO HAVE CHECKED AT THIS EXAMINATION:

PAST MEDICAL HISTORY

Date(Age)Illness, Injury, Hospitalization orSurgery

1.()

2.()

3.()

4.()

5.()

6.()

CIRCLE ANY OF THE FOLLOWING CONDITIONS WHICH YOU NOW HAVE OR HAVE HAD IN THE PAST

Skin Trouble / Tuberculosis / Jaundice / Prostate Trouble / Diabetes
Cataracts / Hardening of Arteries / Gallstones / Syphilis / Mononucleosis
Tonsillitis / Heart Attack / Liver Condition / Gonorrhea / Polio
Sinusitis / Heart Murmur / Hepatitis / Hernia / Diphtheria
Hay Fever / High Blood Pressure / Ulcers / Leukemia / Malaria
Goiter / High Cholesterol / Nervous Stomach/Colon / Cancer or Tumor / Mumps
Thyroid Disorder / High Triglycerides / Diverticulitis / Breast Problems / Measles
Asthma / Stroke / Hemorrhoids / Nervous Breakdown / Chicken Pox
Bronchitis / Paralysis / Kidney Trouble / Anemia / Rheumatic Fever
Emphysema / Unconsciousness / Kidney Stones / Phlebitis / Arthritis
Pneumonia / Fits/Convulsions / Bladder Trouble / Varicose Veins / Gout

LIST ALL MEDICATIONS YOU TAKE REGULARLYOROCCASIONALLY:MEDICATIONALLERGIES:

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SMOKING:CIGARETTES: / Age Began: / CIGARS:
Age Quit: / PIPE:
Packs per day:
ALCOHOL:None / DRUGS: / Marijuana / Depressants
Occasional Social / Cocaine / Hallucinogens
Daily: / Beers per day / Stimulants
Drinks per day
FAMILY HISTORY

(No.) Ages(Living/Dead)Medical Problems/Cause ofdeath

Father: Mother: Brothers:( ) Sisters: ( ) Children: ( )

PLEASE CIRCLE ALL CONDITIONS WHICH BLOOD RELATED FAMILY MEMBERS HAVE OR HAVE HAD:

Tuberculosis / Stroke / Goiter / Nervous/Emotional Disorder
Hypertension / Gall Stones / Thyroid / Alcoholism
Heart Attacks / Kidney Disease / Arthritis/Gout / Epilepsy
Heart Disease / Anemia / Migraine Headaches / Cancer
Diabetes / Bleeding Disorder / Nerve/Muscle Disorder / Leukemia

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REVIEW OF SYSTEMS: Circle YES for any of the following complaints or conditions you have had in the last 3 months. (If you do not understand, place an asterisk * beside “Yes”.)

GENERAL / HEART & LUNGS
Weight gain or loss (over 5 lbs) ...... / Yes / Cough ...... / Yes
Weakness ...... / Yes / Coughing up sputum or blood ...... / Yes
Fatigue ...... / Yes / Shortness of breath ...... / Yes
Fever/Chills ...... / Yes / Wheezing ...... / Yes
Night sweats ...... / Yes / Sleep sitting up/more than two pillows ...... / Yes
Tend to be hot/cold most of the time ...... / Yes / Awaken from sleep short of breath ...... / Yes
SKIN / Pain or tightness in chest:
Change in skin ...... / Yes / when you exercise ...... / Yes
Rash ...... / Yes / when you are nervous ...... / Yes
Itching ...... / Yes / when you have eaten a big meal ...... / Yes
Change in hair ...... / Yes / Heart murmur ...... / Yes
Mole or sore which does not heal ...... / Yes / Swelling of feet/ankles ...... / Yes
HEAD / Pounding/skipping of heart ...... / Yes
Frequent headaches ...... / Yes / Heart starts racing suddenly ...... / Yes
Migraine headaches ...... / Yes / Leg cramps while walking ...... / Yes
EYES / High blood pressure ...... / Yes
Wears glasses ...... / Yes / Fainting ...... / Yes
Blurring of vision ...... / Yes / GASTROINTESTINAL
Double vision ...... / Yes / Loss of appetite ...... / Yes
Blind spots ...... / Yes / Pain/difficulty swallowing ...... / Yes
Light hurts eyes ...... / Yes / Heartburn ...... / Yes
Eye pain ...... / Yes / Belching, bloating, indigestion ...... / Yes
EARS / Nausea/vomiting ...... / Yes
Hearing loss ...... / Yes / Vomiting blood/coffee ground material . . . . . / Yes
Noise in the ears ...... / Yes / Burning or hunger pains relieved by eating
Dizziness or vertigo ...... / Yes / or antacids ...... / Yes
Earache ...... / Yes / Intolerance of fatty foods ...... / Yes
NOSE / Yellow skin or eyes (jaundice) ...... / Yes
Frequent nose bleeds ...... / Yes / Diarrhea ...... / Yes
Stuffy of runny nose ...... / Yes / Constipation ...... / Yes
Postnasal drip ...... / Yes / Cramps in stomach or lower down ...... / Yes
MOUTH & THROAT / Fresh or bright blood in stool
Dentures ...... / Yes / (bowel movement) ...... / Yes
Sore in mouth/on tongue ...... / Yes / Black/tarry stools (bowel movement) ...... / Yes
Sore throat/tonsillitis ...... / Yes / Mucus (slime/phlegm in stool) ...... / Yes
Sore or bleeding gums ...... / Yes / Pain in rectum ...... / Yes
Difficulty speaking ...... / Yes / FEMALE GENITALIA & PREGNANCY
Hoarseness or change in voice ...... / Yes / Number ofpregnancies
NECK / Number ofdeliveries
Pain or stiffness in neck ...... / Yes / Vaginaldeliveries
Swelling of glands in neck ...... / Yes / Cesareandeliveries
Goiter ...... / Yes / Number ofstillbirths
Swelling in neck ...... / Yes / Number ofmiscarriages
MENSES (monthly periods)
The last menstrualperiodbegan Now occursabouteverydays
Normal ...... / Yes / NEUROLOGICAL
Seizures or epilepsy ...... Paralysis ......
Muscle weakness ...... / Yes
Yes Yes
Flooding ...... / Yes / Loss or change in sensation ...... / Yes
Irregular ...... / Yes / Numbness or tingling sensations ...... / Yes
Painful ...... / Yes / Tremor ...... / Yes
Spotting between periods ...... / Yes / Difficulty walking ...... / Yes
Age when “Change of Life” started ...... / Yes / Loss of coordination ...... / Yes
Hot flashes ...... / Yes / Memory change ...... / Yes
Vaginal discharge ...... / Yes / MOOD
Pain with sexual intercourse ...... / Yes / Nervous with strangers ...... / Yes
HysterectomyDate...... / Yes / Difficulty making decisions ...... / Yes
Cause / Lack of concentration or memory ...... / Yes
Birth control pills ...... / Yes / Lonely or depressed ...... / Yes
Lumps or masses in breasts ...... / Yes / Cry often ...... / Yes
Pain in breasts ...... / Yes / Hopeless outlook ...... / Yes
Discharge from breasts ...... / Yes / Difficulty relaxing ...... / Yes
Date of last pelvicexam / Worry a lot ...... / Yes
Date of last PAPsmear / Sexual difficulties ...... / Yes
Name of OB/Gyn Doctor who sees you: / Considered suicide ...... / Yes
MALE GENITAL / IMMUNIZATIONS
Burning/discharge from penis ...... / Yes / (Please enter date of latest immunization)
Sores/ulcers on penis ...... / Yes
Sores/swelling in groin ...... / Yes / Influenza(Flu)
Hernia ...... / Yes
Pain/swelling in testes ...... / Yes / Tetanus/Diptheria(Td)
Infertility problem ...... / Yes
Difficulty in gaining an erection ...... / Yes / Tetanus/Diptheria/Pertussis(TDAP)
Inability to have orgasm (reach climax) . . . / Yes
Trouble starting urination ...... / Yes / Pneumovax
Urine stream has become weak ...... / Yes
UROLOGIC / Zostavax(Shingles)
Pain or burning with urination
(passing water) ...... / Yes / Human Papillomavirus (HPV)
Blood in urine ...... / Yes
Sugar in urine ...... / Yes / Measles/Mumps/Rubella (MMR)
Frequent urination ...... / Yes
Pain over bladder or lower down ...... / Yes / Meningococcal
Hard to empty bladder completely ...... / Yes
Lose control of passing urine ...... / Yes / Hepatitis A
Getting up at night to urinate ...... / Yes
Number oftimes / Hepatitis B

MUSCULOSKELETAL

Back pain ...... Yes

Pain in joints ...... Yes Pain or soreness in muscles ...... Yes

Stiffness in joints or muscles ...... YesBLOOD

Anemia ...... Yes

Bruises easily ...... Yes

Bleeds easily ...... Yes Swelling or soreness anywhere on the body . Yes Armpits or groin swelling ...... Yes