Health History Questionnaire (Page 4 of 4) in pdf

Health History Questionnaire Page 4

GASTROINTESTINAL

! Nausea

! Vomiting

! Diarrhea

! Constipation

! Gas

! Belching

! Black stools

! Blood in stools

! Indigestion

! Bad breath

! Rectal pain

! Hemorrhoids

! Abdominal pain or cramps

! Chronic laxative use

Any other problems with your stomach or intestines?

GENITO-URINARY

! Pain in urination

! Frequent urination

! Blood in urine

! Urgency to urinate

! Unable to hold urine

! Kidney stones

! Decrease in flow

! Impotency

! Sores on genitals

Do you wake up to urinate?

How often?

Any particular color to your urine?

Any other problems with your genital or urinary system?

PREGNANCY & GYNECOLOGY

__ Number of pregnancies

__ Number of births

__ Premature births

__ Number of miscarriages

__ Number of abortions

__ Age of first menses

__ Period between menses

__ Duration

! Unusual characters (heavy or light)

! Clots

! Irregular periods

! Painful periods

! Vaginal sores

! Last PAP

! Vaginal discharge

! Breast Lumps

! Changes in body/psyche prior to menstruation

First date of last menses

Do you practice birth control?

What type and for how long?

MUSCULOSKELETAL

! Neck pain

! Muscle pain

! Knee pain

! Back pain

! Muscle weakness

! Foot/ankle pain

! Hand/wrist pain

! Shoulder pain

! Hip pain

Any other joint or bone problems?

NEUROPSYCHOLOGICAL

! Seizures

! Dizziness

! Loss of balance

! Areas of numbness

! Lack of coordination

! Poor memory

! Concussion

! Depression

! Anxiety

! Bad temper

! Easily susceptible to stress

Have you ever been treated for emotional problems?

Have you ever considered or attempted suicide?

Any other neurological or psychological problems?

COMMENTS

Please list any other problems you would like to discuss:

Health History Questionnaire Page 4

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