Medical History Questionnaire printable pdf download

MEDICAL HISTORY QUESTIONNAIRE

Name: _______________________________ Date of Birth: ___________ Age: _______ Date:____________

Sex: M / F

Current Height: ____________________

Current Weight: ____________________

Primary Care Physician: _________________________Specialty Physician:______________________________

CONDITIONS:

Circle any and all conditions that apply to you or check none.

NONE

fatigue, insomnia, headaches, change in appetite, chills, fever,

GENERAL/CONSTITUTION:

weight loss, weight gain, mood swings, history of MRSA infection

high B/P, heart attack, chest pain, high cholesterol, pace maker,

CARDIOVASCULAR:

irregular heartbeat, mitral valve prolapse, stents

hard of hearing, ear ache, chronic cough,

dry mouth,

sinus/allergy

EARS, NOSE, THROAT:

congestion,

wheezing,

short of breath,

asthma,

COPD,

RESPIRATORY:

emphysema,

TB exposure,

cough, sleep apnea

heartburn, indigestion, diarrhea, constipation, irritable bowel

GASTROINTESTINAL:

syndrome, hepatitis, hernia, ulcers,

nausea,

GERD, abdominal pain

bladder problems, painful urination, kidney stones, blood in urine,

GENITOURINARY:

prostate problems, kidney failure

Are you pregnant? Are you nursing? Ovarian problems

FEMALES:

joint pain,

stiffness,

swelling, fibromyalgia,

rheumatoid arthritis,

MUSCULOSKELETAL:

lupus,

other type arthritis,

osteoporosis, gout,

rashes, eczema, psoriasis, bumps or lumps

INTEGUMENTARY

numbness,

headache,

seizures,

paralysis,

stroke, TIA, dementia,

NEUROLOGICAL:

memory loss, Alzheimer’s, Parkinson’s,

Bell’s Palsy, cerebral palsy

anxiety,

depression,

bi-polar,

agitated,

panic attacks

PSYCHIATRIC:

diabetes, taking insulin,

hypothyroid,

hyperthyroid,

hormone,

ENDOCRINE:

increased thirst, hypoglycemia, Graves Disease,

Thyroid Eye Disease

anemia, bleeding disorder, blood clots, vitamin B12 deficiency,

HEMATOLOGY:

leukemia, lymphoma

sinus,

sneezing,

swelling,

redness,

itching,

hives,

lupus,

ALLERGIC/IMMUNOLOGIC:

HIV,

Herpes Simplex Virus,

Sjogren’s Syndrome

breast,

prostate,

lung,

skin,

colon , other _________________

CANCER:

cataract,

glaucoma, detached retina,

blindness,

lazy eye,

EYE HISTORY:

eye injury/trauma, dry eye, macular degeneration, droopy eyelid

Do you wear glasses?

Do you wear contact lenses?

EYES:

List all Eye Surgeries & Laser Eye Surgeries:

List all OTHER surgeries you have had:

_________________________________________

___________________________________________

_________________________________________

___________________________________________

Have you ever been hospitalized?

Yes

___________________________________________

FAMILY HISTORY: Has any member of your immediate family (blood relatives) have/had these diseases?

Disease/Condition

Family Member

Disease/Condition

Family Member