Patient Health History Questionnaire Template Page 2
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Women's Health Partners, LLC
Patient Health History Questionnaire
Name:
PAST SURGICAL HISTORY:
None
Adenoidectomy
Cystoscopy
Laparoscopy
Appendectomy
D&C
LASIK (eye correction)
Back surgery
Ectopic Pregnancy
LEEP (Cervical Cone biopsy)
Breast augmentation
Endometrial ablation
Ovary Removal
Breast lumpectomy
Gastric Bypass
Pacemaker implant
Breast mastectomy
Hemorrhoid
Shoulder surgery
Bladder lift
Hernia
Sinus surgery
C/Section
Hip replacement
Splenectomy
CABG ( coronary bypass)
Hysteroscopy
Thyroidectomy
Cataracts
Hysterectomy (abdominal)
Tonsillectomy
Cholecystectomy
Hysterectomy (vaginal)
Tubal ligation
/Gallbladder)
Colon resection
Hysterectomy-laparoscopic
Colonoscopy
Knee surgery
Comments:
GENETIC HISTORY:
None
Baby with birth defects
Hemophilia
Tay-Sachs disease
Chromosomal disorder
Mental retardation
Thalassemia
Cystic fibrosis
Muscular dystrophy
Down's Syndrome
Neural tube defects
Fragile X
Sickle cell anemia
Genetic/Inherited disorder
Spinal Muscular Atrophy
Comments:
MEDICATIONS:
None
Medication
Dosage
Frequency
Reason
1.
2.
3.
4.
5.
6.
ALLERGIES:
None
Medication or Substance
Reaction
Medication or Substance
Reaction
1.
3.
2.
4.
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WHP HEALTH QUESTIONNAIRE rev. 04/15
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