Name:

Sex:

DOB:

E-mail Address:

Contact Number:

Marital status:

Previous or referring doctor:

Date of last physical exam:

PERSONAL HEALTH HISTORY

Childhood illness:

Immunizations:

List any medical problems that other doctors have diagnosed

Surgeries:

Year	Reason	Hospital

Other hospitalizations:

Year	Reason	Hospital

Have you ever had a blood transfusion?:

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers:

Name the Drug	Strength	Frequency Taken

Allergies to medications:

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	Sedentary (No exercise) Mild exercise (i.e., climb stairs, walk 3 blocks, golf) Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Diet	Are you dieting? YesNo If yes, are you on a physician prescribed medical diet? YesNo # of meals you eat in an average day? Rank salt intake: HiMedLow Rank fat intake: HiMedLow
Caffeine	NoneCoffeeTeaCola # of cups/cans per day?
Alcohol	Do you drink alcohol? YesNo If yes, what kind? How many drinks per week? Are you concerned about the amount you drink? YesNo Have you considered stopping? YesNo Have you ever experienced blackouts? YesNo Are you prone to “binge” drinking? YesNo Do you drive after drinking? YesNo
Tobacco	Do you use tobacco? YesNo Cigarettes – pks./dayChew - #/dayPipe - #/dayCigars - #/day # of yearsOr year quit
Drugs	Do you currently use recreational or street drugs? YesNo Have you ever given yourself street drugs with a needle? YesNo
Sex	Are you sexually active? YesNo If yes, are you trying for a pregnancy? YesNo If not trying for a pregnancy list contraceptive or barrier method used: Any discomfort with intercourse? YesNo 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? YesNo
Personal Safety	Do you live alone? YesNo Do you have frequent falls? YesNo Do you have vision or hearing loss? YesNo Do you have an Advance Directive or Living Will? YesNo Would you like information on the preparation of these? YesNo 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? YesNo

FAMILY HEALTH HISTORY

	Age	Significant Health Problem
Father
Mother

	Sex	Age	Significant Health Problem
Children	MF
	MF
	MF
	MF

	Sex	Age	Significant Health Problem
Sibling	MF
	MF
	MF
	MF

	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?	YesNo
Do you feel depressed?	YesNo
Do you panic when stressed?	YesNo
Do you have problems with eating or your appetite?	YesNo
Do you cry frequently?	YesNo
Have you ever attempted suicide?	YesNo
Have you ever seriously thought about hurting yourself?	YesNo
Do you have trouble sleeping?	YesNo
Have you ever been to a counselor?	YesNo

WOMEN ONLY

Age at onset of menstruation
Date of last menstruation
Period every _____ days
Heavy periods, irregularity, spotting, pain, or discharge?	YesNo
Number of pregnancies _____ Number of live births _____
Are you pregnant or breastfeeding?	YesNo
Have you had a D&C, hysterectomy, or Cesarean?	YesNo
Any urinary tract, bladder, or kidney infections within the last year?	YesNo
Any blood in your urine?	YesNo
Any problems with control of urination?	YesNo
Any hot flashes or sweating at night?	YesNo
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?	YesNo
Experienced any recent breast tenderness, lumps, or nipple discharge?	YesNo
Date of last pap and rectal exam?

MEN ONLY

Do you usually get up to urinate during the night?	YesNo
If yes, # of times _____
Do you feel pain or burning with urination?	YesNo
Any blood in your urine?	YesNo
Do you feel burning discharge from penis?
Has the force of your urination decreased?	YesNo
Have you had any kidney, bladder, or prostate infections within the last 12 months?	YesNo
Do you have any problems emptying your bladder completely?	YesNo
Any difficulty with erection or ejaculation?	YesNo
Any testicle pain or swelling?	YesNo
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.

Submit