Health Questionnaire
Date _______________ Name _______________________ Age ____________
Right or Left handed
_____________ Height
_______________ Weight ____________
Referred By ___________________ Personal Physician
___________________________________________________
What is the reason for your
visit
today?________________________________________________________________________________________
If result of an ACCIDENT, give
date (s) and
describe:____________________________________________________________________________
Are you employed now?
___________________ Last day worked
________________________ Occupation
_______________________________
Job Duties
_________________________________________________________________ Heavy
lifting yes ___________
or no ____________
PAST MEDICAL HISTORY
Please list any medical
problems for which you regularly see a doctor such as high blood pressure,
diabetes, lung disease, etc.___________________
Have you tested positive for TB
______yes _____no Hepatitis A, B or C _____yes _____no
Surgical: (Please list all surgeries with dates even if unrelated
to today’s visit) ________________________________________________________
Medications: Please list all medications and dosage including
nonprescription pain relievers and vitamin supplements)
Name of Medication/Vitamin Dosage Frequency
of dose
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medication Allergies and
Reactions___________________________________________________________________________________________
Family Medical History (List ages and diseases)
Age Disease
Mother __________ ________________________________________________________________________________________
Father __________ ________________________________________________________________________________________
Sibling (s) __________ ________________________________________________________________________________________
Children __________ ________________________________________________________________________________________
Other Relatives __________ ________________________________________________________________________________________
Social: Marital
Status ___________ Tobacco
Use______________ Alcohol
____________ Illegal Drugs
_____________
Review of Systems
(Check all that apply below if you have
experienced any recent problems in the following categories)
General: Unusual
Weight loss or gain _____Fever __________ Fatigue___________
Skin: History of skin cancer_________ History of Rash_____________
Eyes: Eye Pain _____________Blurred Vision
____________ Double Vision______________
Ears, Nose, Throat:
Hearing loss ________ Sinusitis ________ Ringing in ears _______________
Neck: Neck Stiffness __________
Resp: Asthma ____________ Cough _____________ Shortness of breath_____________
Breast Disease: History of breast disease
_________________________________________________
CV: History of coronary artery disease_________Chest pain
________________ Palpitations ____________________________
GI: Abdominal pain ___ Constipation _____ Diarrhea _____ Nausea____Vomiting____Bleeding
ulcer ________ Bloody Stools ___
GU: Frequency of unination _______Loss of bladder control ____ Blood in urine _____ Burning urination __________________
History of nocturnal urination_________
impotence ________________________
Musculoskeletal:
Joint pain/Arthritis ______________
Muscle Cramps _______ Muscle weakness___________
Neurological: Memory problems _____________ Dizziness
________ Headaches __________ Incoordination or clumsiness_____
Loss of balance
_______________________ Blackouts ________________ Numbness and tingling__________Convulsions
_____________ Confusion ___________ Visual Changes ____________ Weakness_____________Change in voice
___________
Shaking, tremor or jerking
_____________________________
Psychological: Depression ____________ Insomnia _____________________Anxiety
_______________________________
Endocrine: Thyroid Disease _____________ Diabetes ______________
Hematologic: History of free bleeding/easy bruising
___________________ Anemia
____________
Is there any other information
you would like us to know to assist with your problem? __________________________________________________________________________________________________________________
Revised 11/2006