Personal Health History Questionnaire Form
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1
2PERSONAL HEALTH HISTORY QUESTIONNAIRE
DATE: ______________ Health Care Provider: ___________
Patient Name:
Date Of Birth
Age:
Occupation:
Employer:
With Whom Do You Live?
On Whom Do You Depend On For Transportation?
Partner Status: Married
Single
Divorced
Separated
Widowed
Domestic Partner
FAMILY HISTORY
If any blood relative has suffered from any of the following, please check and indicate which relative in the space provided:
Please List ALL Blood Relatives - GP= Grandparent, S= Sibling, M= Mother, F= Father
Alcoholism____________
Clotting Disorders _______
High Cholesterol_________
Stroke _________________
Allergy_______________
Diabetes ______________
Hypertension ___________
Stomach Problems _______
Anemia_______________
Dementia ____________
Mental Illness___________
Tuberculosis ____________
Arthritis ______________
Glaucoma _____________
Migraine_______________
Breast Cancer ___________
Asthma_______________
Heart Disease___________
Osteoporosis____________
Colon Cancer ___________
Seizures________________
Other Cancer ___________
If Mother Deceased, Age & Cause of Death: ________________________________________________________________
If Father Deceased, Age & Cause of Death: _________________________________________________________________
HOSPITAL
YEAR
ILLNESS/OPERATION
YEAR
ILLNESS/OPERATION
ADMISSIONS
(Please Include
Pregnancies &
Past Illnesses)
List Name & Dosage of All Medications That You Are Taking
Please Include
Prescriptions, Supplements, & Non-Prescription Drugs
:
1.
4.
7.
A
2.
5.
8.
3.
6.
9.
ALLERGIES
Please List All Known Allergies, Especially to Medicines or Anesthesia:
List Health Care Providers
Please List The Month & Year Of Your Most Recent: Tests, Exams and Immunizations
That You See Currently (Or Have Seen)
For Your Major Medical Problems
Eye Exam:
Stool Card:
Pneumonia Vaccine (65 yrs. and older):
Diabetic Foot Exam:
PAP Smear:
Shingles Vaccine (60 yrs. and older):
Dental Exam:
Cholesterol Screen:
Hepatitis Vaccine:
Mammogram:
Other Labs:
HPV:
Colonoscopy:
Tetanus Shot (every 10 years):
TB Skin Test:
Sigmoidoscopy:
Flu Shot:
Habits
Smoking; #Cig/Day
For
Yrs.
Alcohol; #Drinks/Day
#Drinks/Mo.
Caffeine; #Cups/Day
Exercise; #Times/Week
Other Drugs
(I.E. Chew Or Illegal Drugs)
WHAT QUESTIONS MAY I ANSWER FOR YOU CONCERNING YOUR HEALTH?
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Parent category: Life