New Patient Health Questionnaire Form Page 3
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4TEXAS CARDIOVASCULAR SPECIALISTS
Family History: Please indicate in the spaces below any family member with a history of: tuberculosis diabetes,
heart disease, cancer, emphysema, kidney disease, asthma, bleeding tendencies, anemia, epilepsy, glaucoma, high
blood pressure, gout, arthritis, ulcer, stroke, nervous breakdown, gall bladder disease.
Age
Health Problem
Age of Death
Cause
_____ ______________________
__________
______________
Father
_____ ______________________
__________
______________
Paternal Grandfather
_____ ______________________
__________
______________
Paternal Grandmother
_____ ______________________
__________
______________
Mother
_____ ______________________
__________
______________
Maternal Grandfather
_____ ______________________
__________
______________
Maternal Grandmother
_____ ______________________
__________
______________
Brother
_____ ______________________
__________
______________
(How many in all?____)
Sister
_____ ______________________
__________
______________
_____ ______________________
__________
______________
(How many in all?____)
_____ ______________________
__________
______________
Son
_____ ______________________
__________
______________
(How many in all?____)
_____ ______________________
__________
______________
Daughter
_____ ______________________
__________
______________
(How many in all?____)
Any other family members with illnesses noted above?____________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
SOCIAL HISTORY
Marital Status:
Married
Separated
Divorced
Widowed
Single
Number of Children: _____________
With whom do you live?______________________________
Family Physician: _______________________________________________________________________________
You’re other physicians:
1.______________________________________________________________________
2.______________________________________________________________________
N/A
What is/was your occupation?______________________________________________________________
YES
NO
Are you retired?
How stressful is your job?
Very
Moderately
Mildly
Not
N/A
Do you take your prescribed medications regularly?
Always
Most of the time
I frequently skip doses
Have you previously smoked?
Never
Yes, but quit YEAR:_________#of packs/day:________ from age:______ to age:________
Years in total smoked ___________
Currently smocking # of packs/day: ________from age_________
Cigars
Pipe
Chew tobacco: times/ day_______
Do you drink alcohol?
Never
No, but I quit YEAR:__________
Yes, _____glasses/week of
wine
beer
liquor
Do you take illicit drugs or abuse prescription medications:
Yes DETAILS:_____________________________
Never
No, but I used to
YES (check all that apply)
Do you drink caffeine?
NO
Coffee
Tea
Colas
Total # Drinks/days:___________
How many times/week do you exercise?____________ How many hours/session?_____________________
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Parent category: Life