Health Fair Toolkit Page 27
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35Confidential Record:
Information contained here will not be released without your authorization.
HEALTH HISTORY FORM
Name
Age:
Date:
Date of Birth:
:
Last
First
M.I.
day/month/year
day/month/year
Address:
Street
City
State
Zip
Telephone:
(Primary)
(Work)
Place of
Occupation:
Employment:
Marital Status:
(circle one)
SINGLE
MARRIED
DIVORCED
WIDOWED
SPOUSE:
Education:
(circle highest level)
ELEMENTARY
HIGH SCHOOL
COLLEGE
GRADUATE
Personal Physician:
Location:
Reason for last doctor visit?
Date of last physical exam?
Reason for today’s visit:
.
Phone
Person to contact in case of an emergency:
#
(relationship)
PLEASE CHECK YES or NO FOR THE FOLLOWING:
PAST HISTORY
FAMILY HISTORY
PRESENT SYMPTOMS
(Have any immediate family or
(Have you ever had?)
YES
NO
YES
NO
(Have you recently had?)
YES
NO
grandparents had?)
High blood pressure .........
Heart attacks ...................
Chest pain/discomfort ......
Any heart trouble .............
High blood pressure .........
Shortness of breath ..........
Disease of the arteries ......
High cholesterol ...............
Heart palpitations .............
Varicose veins ..................
Stroke .............................
Skipped heart beats .........
Lung disease....................
Diabetes ..........................
Cough on exertion ...........
Asthma ............................
Congenital heart defect ....
Coughing of blood ............
Kidney disease .................
Heart operations ..............
Dizzy spells ......................
Hepatitis ..........................
Early death ......................
Frequent headaches .........
Cancer…………………………
Cancer………………………….
Back pain ........................
Diabetes ..........................
Other family illness:
Orthopedic problems ........
Heart murmur ..................
Other:
Arthritis ...........................
Past Surgical History: List date and type of operations
Hospitalizations or Serious Injuries: Please list recent hospitalizations with date and details (Women: do not list normal pregnancies)
Date
Reason
Hospital
Any other medical problems not already identified? Yes
No
(Please list below)
Please turn to next page
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