Health History Form printable pdf download

Marquette University Medical Clinic

Patient Label

Health History Form

Past Medical History

Please check box and briefly explain if you have been diagnosed with any of the following:

Allergies___________________________________________

Anxiety_______________________________________

Depression ___________________________________

Asthma____________________________________________

Diabetes (type I or II)_______________________________

Eating disorder________________________________

Heart condition(eg; murmur)________________________

High Blood Pressure___________________________

Menstrual disorder (irregular, amenorrhea, cramps)____ Thyroid disease________________________________

Other problem(s) not listed_______________________________________________________________________________

Please list any hospitalizations, significant injuries, or surgeries:

__________________________________________________________________________________________________________

Social History

How often do you have a drink with alcohol?

 Never

 ≤once a month

 2-4 times a month

 2-3 times a week

 ≥4 times a week

How many drinks at a time?

 1-2

 3-4

 5-6

 7-9

 ≥10

How many times in the last 3 months have you had five or more drinks in a day (if you’re a man), or four or more

drinks (if you’re a woman)? _______________

Is alcohol a concern for you or others? ____yes ____no

Do you use tobacco? ____ yes ____ no

Are you interested in quitting? ____ yes ____ no

Are you Sexually Active? ____ yes ____ never ____ not currently

Number of partners in lifetime_______

Have you ever had any sexually transmitted diseases? ____ yes ____ no

Are you interested in being screened for STDs? ____ yes ____ no

Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? ____ yes ____ no

If so, by whom? _____________________________

Do you feel safe in your current relationship? ____ yes ____ no

Is there a partner from a previous relationship making you feel unsafe now? ____ yes ____ no

During the past month:

Have you often been bothered by feeling down, depressed, or hopeless?

____ yes

____ no

Have you often been bothered by little interest in pleasure in doing things?

____yes

____ no

Please list all medications you take regularly (include birth control pills, non-prescription drugs,

vitamins, herbal supplements___________________________________________________________________________

Please list any medication allergies______________________________________________________________________

Family History

Please check box if any family members (parents, siblings, grandparents, aunts or uncles) have been

diagnosed with any of the following conditions:

Heart disease

High Cholesterol

Diabetes

Tuberculosis

High Blood Pressure

Stroke

Alcoholism

Depression

Other mental illness

Cancer (type)_______________________________

Women’s Health History

First day of last period ______________ Number of periods in last 12 months _________ Age periods began ________

Date of last PAP smear/pelvic exam ______________

 Normal

 Abnormal

Have you ever had an abnormal PAP smear? _______________________________

RB 7/31/13

Health History Form

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