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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
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