Patient Questionnaire Form

ADVERTISEMENT

POLYCLINIC
PLEASE PRINT
PLEASE PRINT
THIS INFORMATION BECOMES PART OF YOUR CONFIDENTIAL MEDICAL RECORD.
NAME
Type of Work _______________________________________
Marital/Partner Status ________________________________
LAST
FIRST
MIDDLE INITIAL
Education (years completed)
How would you like to be addressed by our staff (i.e., Mr./Ms.
______
GRADE________ HIGH ________ VOCATIONAL ________ COLLEGE
or first name)? _________________________________________
Previous Primary Care Physician _______________________
ADDRESS ____________________________________________
Other treating physician(s) ____________________________
_____________________________________________________
Last eye exam______________ Last dental exam __________
PHONE(s) ____________________________________________
Last tetanus shot ____________________________________
PAST HISTORY
(GIVE NAMES AND DATES)
PREVIOUS SURGERY
PREVIOUS
HOSPITALIZATIONS
MAJOR ILLNESS
OR
INJURY
AGE IF
AGE AT
PRESENT CONDITION OR
CHECK IF ANY
FAMILY HISTORY
LIVING
DEATH
CAUSE OF DEATH
RELATIVES HAVE HAD:
FATHER
DIABETES ........................................................
MOTHER
HEART TROUBLE ............................................
HEART ATTACK ...............................................
BROTHERS:
HIGH BLOOD PRESSURE ..............................
NUMBER:________
STROKE ...........................................................
CANCER ..........................................................
TUBERCULOSIS ..............................................
SISTERS:
MELANOMA .....................................................
NUMBER:________
ARTHRITIS .......................................................
OBESITY (OVERWEIGHT) ..............................
SUICIDE ...........................................................
CHILDREN:
MENTAL ILLNESS ............................................
NUMBER:________
THYROID TROUBLE ........................................
______________________________________
NUMBER LIVING IN YOUR HOUSEHOLD _______________
SMOKING:
ALCOHOL:
CAFFEINE
WEAR HELMET
SMOKE
ANY RISK FACTORS
WHEN BIKING?
ALARMS?
FOR HEPATITIS OR AIDS
(coffee, tea, cola):
PACKS PER DAY ___________
PER DAY _________
(SUCH AS BLOOD TRANSFUSIONS,
YES
NO
YES
NO
SEXUAL CONTACTS, IV DRUG USE)?
NO. YEARS _______________
PER WEEK _______
CUPS PER DAY ______
ASPIRIN
YES
NO
USE CAR SEAT BELTS?
YEAR STOPPED ___________
ALCOHOL PROBLEM
LET’S DISCUSS
PIPE
CIGAR
CHEW
YES
NO
TABS PER DAY __________
YES
NO
WEIGHT:
HEIGHT:_________
CURRENT________
1 YEAR AGO ________ GOAL: ________
Prescription Drugs
Over the counter Drugs and Supplments
Herbal
DRUGS FREQUENTLY
OR PRESENTLY USED
SPECIFY ANY DRUG REACTION OR ALLERGY: ________________________________________________________________________________
5000990713
#5000990911

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2