Health Questionaire Form
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1
2HEALTH
Patient’s Name
QUESTIONNAIRE
MRN
DOB
Patient Name: ______________________________
DOB: _____________________________________
Please indicate each of your chronic medical problems by marking the appropriate box below:
q High Blood Pressure
q Asthma
Please list any other medical problems:
q Heart Disease
q Emphysema/Lung Disease
q Diabetes
q Kidney Problems
q Stroke
q Anemia
q Cancer
q High Cholesterol
q Thyroid
q Glaucoma
Please list all medications that you are now taking, strength (in milligrams) and how often. Include
non-prescription medications, vitamins and herbal supplements.
Are you allergic to any medications? o Yes o No If yes, please list them and the reaction they cause.
Do you require assistance for hearing impaired? o Yes o No
Social History
Tobacco
___________ a day
Number of years
__________ Year Quit ________
Alcohol
___________ drinks per week
Caffeine____________________________cups a day
Low fat diet o Yes o No
Street Drugs
___________
Exercise
___________ type
Times a week
__________ minutes/session
Water
___________ cups a day
Marital Status
__________
# of Children
___________
Occupation __________________________________
Do you have a living will? o Yes o No
o Yes o No
If yes, have you given us a copy?
Family History
If any blood relative has suffered from the following conditions, check the box and indicate which relative.
o Heart Disease
o Stroke
o Asthma
o Glaucoma
o Diabetes
o High Blood Pressure
o Emphysema/Lung Disease
o Mental Health
o Thyroid
o High Cholesterol
o Cancer
o Substance Abuse
OVER
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Parent category: Life