Health Questionnaire

Name:

Date:

Date of Birth:

Chief Complaint:

Brief History of Problem:

Surgical History:

Other:

Habits:

Alcohol #drinks/week

Cigarettes: #cig/day

Cigarettes: #years

Cigarettes: year quit

Other tobacco usage:

Current frequency:

Caffeine #cups/day

Recreational Drugs

Women only:

Date of last PAP test

Normal? Abnormal?

Date of last mammogram

Normal? Abnormal?

Date of last period (1st day)

Menopausal symptoms?

Irregular periods?

Menstrual pain?

Pre-menstrual complaints?:

History of pregnancies:

Other:

Allergies:

Current Medications:

Add medication

Review of Current/Recent Symptoms: (select all those that are applicable)

General

Fever

Chills

Weight Loss

Weakness

Skin

Rash

Itching

Hematopoietic

Bruising

Bleeding

Anemia

HEENT

Vision change

Double vision

Glaucoma

Hearing problems

Vertigo

Respiratory

Cough

Coughing Blood

Shortness of Breath

Infections

Cardiovascular

Chest Pain

Murmurs

Pain in legs with walking

Swelling in the legs

Gastro-Intestinal

Constipation

Diarrhea

Bleeding

Hemorrhoids

Indigestion

Hepatitis

Genito-Urinary

Burning

Bleeding Leaking (incontinence)

Flank pain

Loss of erections

Muscle-skeletal

Joint pain

Weakness

Back pain

Cramps

Neurologic

Headache

Dizziness

Seizures

Blackouts

Depression

Sleeping problems

Other:

Other Comments:

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