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HEALTH QUESTIONNAIRE
Today's Date
Age
Sex
Female
Male
Select
Address
City/State/Zip
Home Phone
Work Phone
Cell
Date of Birth
What is today's complaint?
HISTORY OF PAST ILLNESSES
Measles
*
Yes
No
Mumps
*
Yes
No
Chicken Pox
*
Yes
No
Rheumatic Fever or Heart Disease
*
Yes
No
Venereal Disease (Syphllis, Gonorrhea, Herpes, etc)
*
Yes
No
Congenital abnormalities
*
Yes
No
Other serious illnesses or injuries
*
Yes
No
If yes, describe
Were you ever hospitalized?
*
Yes
No
If yes, describe
Have you ever had surgery?
*
Yes
No
If yes, list with age or year of operation
Do you have any implants?
*
Yes
No
Do you drink alcoholic beverages?
*
Yes
No
Rarely - Moderately - Daily
Do you use tobacco?
*
Yes
No
Cigarettes - Cigars - # per day
Do you use recreational drugs?
*
Yes
No
Are you exposed to fumes, dust, solvents on the job or at home?
*
Yes
No
Are you now taking any medications or vitamin supplements?
*
Yes
No
If yes, please list:
Have you or any family member ever had:
Cancer
*
Yes
No
Tuberculosis
*
Yes
No
Diabetes
*
Yes
No
Heart Trouble or High Blood Pressure
*
Yes
No
Stroke
*
Yes
No
Convulsions
*
Yes
No
Insanity
*
Yes
No
Bleeding tendency
*
Yes
No
Gout or other arthritis
*
Yes
No
Other, please list:
SYSTEMIC REVIEW: Do you have any of the following?
Skin: Hives, eczema, rash, boils, warts
*
Yes
No
Head-Eye-Ears-Nose-Throat:
Headaches
*
Yes
No
Do you wear glasses?
*
Yes
No
Itching eyes or nose
*
Yes
No
Sneezing, nosebleeds or runny nose
*
Yes
No
Chronic sinus trouble
*
Yes
No
Impaired hearing
*
Yes
No
Dizziness or transient episodes of unconsciousness
*
Yes
No
Respiratory:
Chronic or frequent cough
*
Yes
No
Difficulty breathing, asthma, emphysema, wheezing
*
Yes
No
Cardiovascular:
Chest pain or angina pectoris
*
Yes
No
Shortness of breath when walking or lying down
*
Yes
No
Difficulty walking two blocks
*
Yes
No
Heart trouble, heart attack, heart murmur
*
Yes
No
High blood pressure or Low blood pressure
*
Yes
No
Swelling of hands, feet or ankles
*
Yes
No
Awakening in the night smothering
*
Yes
No
Gastrointestinal:
Vomiting blood or food
*
Yes
No
Bleeding with bowel movements or black stools
*
Yes
No
Hemorrhoids, piles or painful bowel movements
*
Yes
No
Recent changes in bowel habits
*
Yes
No
Frequent diarrhea or constipation
*
Yes
No
Heartburn, indigestion, ulcers, colitis
*
Yes
No
Genitourinary:
Frequent or nighttime urination
*
Yes
No
Burning or painful urination
*
Yes
No
Blood in urine
*
Yes
No
Gynecological:
Age period started
How long do periods last (Days)
Number of pregnancies
Number of miscarriages
Number of children (Include ages)
Date of last pap smear and results
First day of last period
Frequency of periods, every (Days)
Any pain with periods
Yes
No
Locomotor-Musculoskeletal:
Weakness of muscles or joints
*
Yes
No
Any difficulty walking or exercising
*
Yes
No
Hematologic:
Anemia or Hemophilia
*
Yes
No
Phlebitis
*
Yes
No
Endocrine:
Thyroid Disease
*
Yes
No
Hormone Therapy
*
Yes
No
Have you become colder than before
*
Yes
No
Has your skin become drier
*
Yes
No
Recent weight change
*
Yes
No
ALLERGIES AND SENSITIVITIES
Is there a history of skin reaction or other abnormal reaction to or sickness following injection or oral administration of:
Antibiotics: (penicillin, sulfa, etc)
*
Yes
No
Narcotics: (morphine, codeine, demerol, etc)
*
Yes
No
Anesthesia: (novocaine, lidocaine, etc)
*
Yes
No
Pain Remedies (aspirin, Empirin, Tylenol, etc)
*
Yes
No
Vaccines (smallpox, tetanus, etc)
*
Yes
No
Iodine or merthiolate
*
Yes
No
Adhesive tape, plastics, etc
*
Yes
No
Any foods: (eggs, milk, chocolate, caffeine, etc)
*
Yes
No
Other: Please list:
Submit
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