HEALTH HISTORY QUESTIONNAIRE

    All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

    PERSONAL HEALTH HISTORY

    Year

    Reason

    Hospital

    Year

    Reason

    Hospital

    Name the Drug

    Strength

    Frequency Taken

    Name the Drug

    Reaction You Had

    HEALTH HABITS AND PERSONAL SAFETY

    All questions contained in this questionnaire are optional and will be kept strictly confidential.


    Exercise

    Diet

    Are you dieting?

    If yes, are you on a physician prescribed medical diet?

    # of meals you eat in an average day?

    Rank salt intake:

    Rank fat intake:

    Caffeine

    # of cups/cans per day?

    Alcohol

    Do you drink alcohol?

    If yes, what kind?

    How many drinks per week?

    Are you concerned about the amount you drink?

    Have you considered stopping?

    Have you ever experienced blackouts?

    Are you prone to “binge” drinking?

    Do you drive after drinking?

    Tobacco

    Do you use tobacco?

    Drugs

    Do you currently use recreational or street drugs?

    Have you ever given yourself street drugs with a needle?

    Sex

    Are you sexually active?

    If yes, are you trying for a pregnancy?

    If not trying for a pregnancy list contraceptive or barrier method used:

    Any discomfort with intercourse?

    Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?

    Personal Safety

    Do you live alone?

    Do you have frequent falls?

    Do you have vision or hearing loss?

    Do you have an Advance Directive or Living Will?

    Would you like information on the preparation of these?

    Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?


    FAMILY HEALTH HISTORY


    Age

    Significant Health Problem

    Father

    Mother


    Sex

    Age

    Significant Health Problem

    Children


    Sex

    Age

    Significant Health Problem

    Sibling


    Age

    Significant Health Problem

    Grand Mother (Maternal)

    Grand Father (Maternal)


    Age

    Significant Health Problem

    Grand Mother (Paternal)

    Grand Father (Paternal)


    MENTAL HEALTH


    Is stress a major problem for you?

    Do you feel depressed?

    Do you panic when stressed?

    Do you have problems with eating or your appetite?

    Do you cry frequently?

    Have you ever attempted suicide?

    Have you ever seriously thought about hurting yourself?

    Do you have trouble sleeping?

    Have you ever been to a counselor?


    WOMEN ONLY


    Age at onset of menstruation

    Date of last menstruation

    Period every _____ days

    Heavy periods, irregularity, spotting, pain, or discharge?

    Number of pregnancies _____ Number of live births _____

    Are you pregnant or breastfeeding?

    Have you had a D&C, hysterectomy, or Cesarean?

    Any urinary tract, bladder, or kidney infections within the last year?

    Any blood in your urine?

    Any problems with control of urination?

    Any hot flashes or sweating at night?

    Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?

    Experienced any recent breast tenderness, lumps, or nipple discharge?

    Date of last pap and rectal exam?


    MEN ONLY


    Do you usually get up to urinate during the night?

    If yes, # of times _____

    Do you feel pain or burning with urination?

    Any blood in your urine?

    Do you feel burning discharge from penis?

    Has the force of your urination decreased?

    Have you had any kidney, bladder, or prostate infections within the last 12 months?

    Do you have any problems emptying your bladder completely?

    Any difficulty with erection or ejaculation?

    Any testicle pain or swelling?

    Date of last prostate and rectal exam?


    OTHER PROBLEMS


    Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.