Health History Questionnaire Form - Jupiter Medical Center
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2WELLNESS SERVICES
Health History Questionnaire
Name_____________________________________________ Date _________________________________________
Address __________________________________________
Occupation ___________________________________
City_________________________
Zip_______________
JMC employee___________ Auxiliary______________
Home Phone ______________________________________
Work Number__________________________________
Emergency Contact___________________________
Birthdate____/____/_____
Male __ Female ___
Address ____________________________________ Relationship __________________ Phone # ________________
Primary Care Physician ________________________________Primary Care Physician Phone ___________________
How did you hear about our program(s)? friend ___ physician___ newspaper___ other (explain) _____________
Please answer the following, as they apply to you, by checking the appropriate box:
(Y=Yes
N=No)
Y
N
Y
N
Heart attack - date ___________
Anemia
Physician diagnosed heart trouble
Arthritis
* irregular heart beat
Back pain
* heart murmur
Bursitis
* heart valve problems
Chronic recurrent cough
* rheumatic heart disease
Gout
* angina
Hernia
Stroke- date___________
Phlebitis
COPD- emphysema,
Epilepsy
Diabetes - is it controlled?___________
Low blood pressure (ie 90/50)
Cancer - under current treatment
Fibromyalgia
Bone/Joint/Fracture disorder
Osteoporosis
High Cholesterol level___________
Have you ever smoke? How long________
date tested___________
Do you presently smoke. How much______
Pregnant:
Due date___________
Other: ___________
Hypertension - Is it controlled ___________
FAMILY HISTORY
Please check the appropriate boxes if any of YOUR IMMEDIATE BLOOD FAMILY
MEMBERS have had or currently have the following conditions:
___ Heart attack
___ Angina
___ Heart failure
___ Angioplasty
___ Heart surgery
___ Vascular disease
___ Stroke
___ High cholesterol
PERSONAL HISTORY ( SURGERY)
.
Please check the appropriate boxes if you have had the following surgeries
___ Back surgery / date___________
____ Heart surgery / date__________
___ Joint surgery / date___________
Other__________________________
Have you ever participated in any rehab programs? Cardiac ____Physical Therapy ____Pulmonary____
If you checked one, where________________________________________________________________
Please list any medication/supplements that you are currently taking (name and reason):
Please list any food or drug allergies:___________________________________________________________
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