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


    Year Reason Hospital

    Year Reason Hospital

    Name the Drug Strength Frequency Taken

    Name the Drug Reaction You Had


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


    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:


    # 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?


    Age Significant Health Problem
    Sex Age Significant Health Problem
    Sex Age Significant Health Problem
    Age Significant Health Problem
    Grand Mother (Maternal)
    Grand Father (Maternal)
    Age Significant Health Problem
    Grand Mother (Paternal)
    Grand Father (Paternal)


    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?


    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?


    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?


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