Medical History Questionnaire
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1MEDICAL HISTORY QUESTIONNAIRE
Patient Name ______________________________________________________________ Chart# ___________________________________
Date of birth ______________________ Age ___________ Sex ___________ Height ___________ Weight ___________
(For office use only: BP ______________ Pulse ______________)
Who referred you for this visit; if not referred, please indicate __________________________________________________________________
Reason for seeing Doctor: ______________________________________________________ ____________Injury? Yes or No
Worker’s Comp ___________ Auto Accident ________ Sports ______________ Date of Injury/Onset_______________________
Past Medical History
Do you have, or have you had, any of the following: (PLEASE CIRCLE)
Diabetes
High blood pressure
Heart condition
Seizure
Sleep apnea
Ulcer
Cancer
Blood or bleeding disorder
Phlebitis or blood clots
Stroke
Asthma
Emphysema
Complication of anesthesia
Kidney stones
List other medical conditions and/or illnesses not mentioned above _____________________________________________________________
___________________________________________________________________________________________________________________
List reasons for hospitalizations and/or surgeries with dates and any complications _________________________________________________
___________________________________________________________________________________________________________________
List any significant injuries you have sustained _____________________________________________________________________________
List current medications _______________________________________________________________________________________________
___________________________________________________________________________________________________________________
List any Drug Allergies ________________________________________________________________________ / Latex Allergy? Yes or No
Family History (if deceased, please provide age and cause)
Age(s) and overall health of parents _____________________________________________________________________________________
Age(s) and overall health of sibling(s) ____________________________________________________________________________________
List any significant family health problems ________________________________________________________________________________
Social History
Marital status ________________ Education (Years/Degrees) _________________________________________________________________
Alcohol use (type/amount) _______________________________ Tobacco use (amount/years used) __________________________________
Employer _________________________________________________________ Occupation _______________________________________
Review of Systems (Circle positive symptoms and describe and/or add others, if needed.)
Constitutional: Fever, weight gain/loss, loss
Urologic: Pain when urinating,
Endocrine: Excessive thirst,
of appetite
hesitancy, bleeding, incontinence
excessive urination, heat/cold
intolerance
Eyes: Double vision, blurring, difficulty seeing
Skin: Rashes, lesions that do not
Blood and Lymph: Anemia,
heal, changes in moles
ENT: Deafness, sinusitis, hoarseness, vertigo
bleeding tendencies, swollen nodes
Gynecologic: Breast masses, pain,
Cardiovascular: Chest pain, murmur
discharge, problems
Allergic and Immunologic: Hives,
palpitations, irregular/rapid heartbeat
eczema, itching
Neurologic: Seizures, loss of
Respiratory: Shortness of breath,
balance/coordination, paralysis,
Musculoskeletal: Stiffness, joint
wheezing, spitting blood, chronic cough
weakness, loss of memory
pain/deformity, muscle wasting,
spine pain radiating to arm/leg
Digestive: Abdominal pain, constipation,
Psychiatric: Depression, anxiety,
diarrhea, bleeding
hallucinations, sleep disturbances
Other: _____________________________________________________________________________________________________________
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_______________
________________________________________
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Patient Signature
Date
Physician Signature
Date
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