Health History Form

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DALLAS DIAGNOSTIC ASSOCIATION
HEALTH HISTORY FORM
Name ________________________________________________ Date of Birth _________________ Date __________________
Welcome to our practice!! We are happy you chose us to assist you with your health care needs. Please help us by completing both
sides of this form. This is a confidential record that will be kept in your chart in this office.
Who referred you? ______________________________________________________________
Past Medical History: Have you ever had the following? (Circle yes or no. Leave blank if you are unsure.)
Chicken pox . . . . . . . . no
yes
Hives or Eczema . . . . . no
yes
Any other disease (please list)
Measles . . . . . . . . . . . . no
yes
Migraines . . . . . . . . . . . no
yes
_____________________________________
Mumps . . . . . . . . . . . . no
yes
Seizures . . . . . . . . . . . . no
yes
_____________________________________
Infectious Mono . . . . . . no
yes
Stroke . . . . . . . . . . . . . . no
yes
When was your last:
Tuberculosis . . . . . . . . . no
yes
Anemia . . . . . . . . . . . . . no
yes
Pap smear ____________________________
Pneumonia . . . . . . . . . . no
yes
Bleeding tendency . . . . no
yes
Mammogram _________________________
Asthma . . . . . . . . . . . . . no
yes
Blood transfusion . . . . . no
yes
Breast exam __________________________
Emphysema . . . . . . . . . no
yes
AIDS/HIV . . . . . . . . . . no
yes
Prostate exam _________________________
Rheumatic Fever . . . . . no
yes
Venereal disease . . . . . . no
yes
PSA test _____________________________
Mitral valve prolapse . . no
yes
Bladder infections . . . . no
yes
Stool test for blood _____________________
Heart Disease . . . . . . . . no
yes
Kidney disease . . . . . . . no
yes
Colonoscopy __________________________
Heart Attack . . . . . . . . . no
yes
Ulcer . . . . . . . . . . . . . . no
yes
Chest Xray ___________________________
High blood pressure . . . no
yes
Hepatitis . . . . . . . . . . . . no
yes
Tuberculosis skin test (PPD) _____________
High cholesterol . . . . . . no
yes
Liver disease . . . . . . . . no
yes
Tetanus shot __________________________
Thyroid disease . . . . . . no
yes
Gallbladder problem . . no
yes
Pneumonia shot _______________________
Diabetes . . . . . . . . . . . . no
yes
Hemorrhoids . . . . . . . . no
yes
Flu shot ______________________________
Cancer . . . . . . . . . . . . . no
yes
Hernia . . . . . . . . . . . . . no
yes
Hepatitis A & B shots __________________
Emotional problem . . . no
yes
Osteoporosis . . . . . . . . no
yes
Vaccinations __________________________
Glaucoma . . . . . . . . . . . no
yes
Back problems . . . . . . . no
yes
Bone Density _________________________
Allergies/Hayfever . . . . no
yes
Arthritis . . . . . . . . . . . . no
yes
EKG/Stress test _______________________
Serious Illnesses, Surgeries & Hospitalization: (please list with date of occurrence)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Allergies: (foods, drugs) Please indicate type of reaction.
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Family History: Please indicate in the spaces below any family members 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 Problems
Age at Death
Cause
Father
_________ _________________________________________ _________ ________________________
Paternal Grandfather
_________ _________________________________________ _________ ________________________
Paternal Grandmother
_________ _________________________________________ _________ ________________________
Mother
_________ _________________________________________ _________ ________________________
Maternal Grandfather
_________ _________________________________________ _________ ________________________
Maternal Grandmother
_________ _________________________________________ _________ ________________________
Brothers
_________ _________________________________________ _________ ________________________
(how many in all? ____) ___________________________________________________ _________ ________________________
Sisters
_________ _________________________________________ _________ ________________________
(how many in all? ____) ___________________________________________________ _________ ________________________
Sons
_________ _________________________________________ _________ ________________________
(how many in all? ____) ___________________________________________________ _________ ________________________
Daughters
_________ _________________________________________ _________ ________________________
(how many in all? ____) ___________________________________________________ _________ ________________________
Any other family members with illnesses noted above? _______________________________________________________________
___________________________________________________________________________________________________________
Social History:
Marital Status: _______________ Highest level of education: __________________Occupation: ___________________________
Frequency/amount of alcohol use: ________________________ Frequency/amount of tobacco use: _________________________
Frequency/amount of drug use: ___________________________ Frequency/amount of caffeine: ____________________________
Frequency/amount of exercise: ___________________________
(over)

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