Health History Questionnaire Physical (Page 2 of 4) in pdf

PERSONAL HEALTH ASSESSMENT: For the following questions, please check yes if you are presently having a

problem or have had a problem in the past. If there is no significant problem, check no. Briefly explain all yes answers.

TO BE COMPLETED BY STUDENT.

Drug Usage:

Yes

Past Illness:

Yes

Please give information about drug usage

Malaria, Hepatitis, mononucleosis, Chicken pox and

alcohol, marijuana, smoking……………



other childhood diseases



_________________________________

Loss or absence of any body parts.

Severe/frequent colds or flu…………



_________________________________

Cardiovascular:

Hospitalization:



Heart murmur/palpitations………………......

Have you ever been admitted to a

Chest Pain………………………………….



hospital?................................................

Rheumatic fever…………………………….



Have you ever had surgery?................

High blood pressure……………………….



_____________________________

Irregular heartbeat………………………….



Blood clots (not menstrual clots)…………..

EENT:



Enlarge heart………………………………

Any problems with your eyes, ears, nose, or



__________________________________

throat…………………………………

Hearing impairment……………………



Loss of eye or eyesight……………….



Respiratory:

Asthma………………………………………



Chest infection………………………………



Blood:



Anemia………………………………… 



Do you smoke cigarettes?.............................

Sickle-cell disease…………………..



How many?______How Long?________

Shortness of breath…………………………



Abnormal bleeding or bruising……..….. 



Wheezing……………………………………



Skin:



Any problems with your skin?....................

Bone and Joint:

Skin rashes………………………………….



Any serious disability deformity or

disease of bone, joint, or muscle?........... 



__________________________________

______________________________

Endocrine:

Neurology:

Thyroid disease…………………………….



Seizures or convulsions……………



Diabetes……………………………………..

Fainting or blackouts………………

Dizziness…………………………….



Urinary:

Gastrointestinal:

Impaired function of any part of your

Problems with any part of your intestinal



tract or stomach?...................................... 



Urinary tract or loss of a kidney

Jaundice………………………………… 



_______________________________

Hernia…………………………………… 



Kidney Stones:……………………………

_______________________________

Mental Health:

Reproductive System (men):

Prostate trouble…………………………. 



Any problems with your emotional health,



Swelling of the scrotum or testicle…….

requiring any form of therapy, including



Undescended or absent testicle………..



medications?...............................................

Do you perform testicular self-



Have you ever experienced a serious

examination?_____________________



dietary problem (anorexia, bulimia, obesity)

Medications:

Reproductive System (women):



(birth control pills, vitamins, over-the counter-

Never had a menstrual period?..............



Any form of menstrual disorder?............ 



medications and prescriptions):

Do you perform breast self-exam……… 



Amount:____________________________

Usage Per day:_______________________

Last menstrual period______________

Health History Questionnaire Physical Page 2

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