Health Questionaire Form Page 2
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2Patient Name:____________________________________
Please list any surgeries/hospitalizations (including the year):
Are you under the care of any other doctor for any medical problems? ____________________________
If so, whom and for what medical problem? _________________________________________________
Year of last: Tetanus Shot _______
Flu Shot
__________
Pneumonia Vaccine _______
Women only: Date of first day of last menstrual period: ___/___/___
Contraception Type _______
Number of:
Pregnancies _______
Live Births __________
Miscarriages _______
Abortions __________
Date of last:
PAP _______ (Abnormal?_______)
Mammogram _______ (Abnormal?_______)
Flushing/Menopausal Symptoms o Yes o No
Date of last:
Osteoporosis Scan ______________
Have you been a victim of abuse? o Yes
o No
Men only:
Date of last: Prostate Exam _______
Last PSA (Prostate Blood Test) _______
Procedures (list year):
Sigmoidoscopy
Colonoscopy
Stress Test
EKG
Cholesterol (normal Y/N)
Sugar (normal Y/N)
Please place a checkmark next to any symptoms that you are currently having and indicate the
year if the symptoms occurred in the past.
o Fever
o Night Sweats
o Unexplained Weight Loss or Gain
o Fatigue
GENERAL
o Rashes
o Cancers
o Change in Hair, Skin or Nails
SKIN
o Glasses
o Contact Lenses
o Pain
o Changing Vision
o Discharge
EYES
o Ear Pain
o Change in Hearing o Persistent Runny Nose
EAR NOSE
o Sore Throat
o Change in Voice
o Sinus Trouble
THROAT
o Chest Pain
o Swelling in Ankles o Palpitations o HeartMur mur
HEART
o Cough
o Short of Breath
o Wheeze
LUNGS
o Nausea
o Blood in Stool
o Change in Bowel Movements
GASTRO-
o Ulcers
o Heartburn
INTESTINAL
o Blood in Urine o Painful or Frequent Urination
o Incontinence
GENITO-
o Sexually Transmitted Disease
URINARY
o Vaginal Discharge
o Change in Menstrual Cycle or Sexual Function
Women:
o Testicular Pain
o Decreased Urinary Stream
Men:
o Penile Discharge
o Change in Sexual Function
o Painful Joints
o Muscle Weakness
ORTHOPEDIC
o Seizures
o Tremor
o Paralysis
o Frequent Headaches
NEURO/PSYCH
o Depression
o Anxiety
o Hives
o HayF ever
ALLERGY
o Leg Swelling
o Blood Clots
CIRCULATION
Patient Signature
Date
Clinician Signature
Date
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Parent category: Life