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Original Date:Dates Revised:HEALTH HISTORY QUESTIONNAIREAll questions contained in this questionnaire are strictly confidential and will become part of your medical record.Name (Last, First, M.I.):How you prefer to be addressed: DOB:?Male ?Female?Other Preferred pronouns:Marital status: ? Single ? Partnered ? Married ? Separated ? Divorced ? WidowedPrevious or referring doctor:Date of last physical exam:PERSONAL HEALTH HISTORYChildhood illness:? Measles ? Mumps ? Rubella ? Chickenpox ? Rheumatic Fever ? PolioImmunizations and dates:? Tetanus? Pneumonia? Meningitis? Hepatitis? Chickenpox? COVID-19? HPV? MMR Measles, Mumps, Rubella ? FluList any medical problems that other doctors have diagnosedSurgeriesYearReasonHospitalOther hospitalizationsYearReasonHospitalHave you ever had a blood transfusion??Yes?NoPlease turn to next pageList your prescribed drugs and over-the-counter drugs, such as vitamins and inhalersName the DrugStrengthFrequency TakenAllergies to medicationsName the DrugReaction You HadHEALTH HABITS AND PERSONAL SAFETYAll 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)DietAre you dieting??Yes?NoIf yes, are you on a physician prescribed medical diet??Yes?No# of meals you eat in an average day?Rank sugar/carb intake? Hi? Med? LowRank fat intake? Hi? Med? LowCaffeine? None? Coffee? Tea? Cola# of cups/cans per day?AlcoholDo you drink alcohol??Yes?NoIf yes, what kind?How many drinks per week?Are you concerned about the amount you drink??Yes?NoHave you considered stopping??Yes?NoHave you ever experienced blackouts??Yes?NoAre you prone to “binge” drinking??Yes?NoDo you drive after drinking??Yes?NoTobaccoDo you use tobacco??Yes?No ? Cigarettes – pks./day ? Vape- %/cartridge? Chew - #/day? Cigars - #/day? Pipe - #/day? # of years? Or year quitDrugsDo you currently use recreational or street drugs??Yes?NoHave you ever given yourself street drugs with a needle??Yes?NoSexAre you sexually active??Yes?NoAre you interested in males, females, or other?If not trying for a pregnancy list contraceptive or barrier method used:Any concerns for sexually transmitting infections??Yes?NoIllness 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??Yes?NoPersonal SafetyDo you live alone??Yes?NoDo you have frequent falls??Yes?NoDo you have vision or hearing loss??Yes?NoDo you have an Advance Directive or Living Will??Yes?NoWould you like information on the preparation of these??Yes?NoPhysical 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??Yes?NoFAMILY HEALTH HISTORYAny family history of: heart disease, heart attack, a.fib, strokes, heart murmurs, chronic lung disease, kidney disease, cancer (breast, colon, prostate), thyroid disease, mental illness, alcohol abuse, autoimmune conditions (rheumatoid arthritis, lupus), clotting disorders, bleeding disordersvAgeSignificant Health ProblemsAgeSignificant Health ProblemsFatherChildren? M? FMother? M? FSibling? M? F? M? F? M? F? M? F? M? FGrandmotherMaternal? M? FGrandfatherMaternal? M? FGrandmotherPaternal? M? FGrandfatherPaternalMENTAL HEALTHIs stress a major problem for you??Yes?NoDo you feel depressed??Yes?NoDo you panic when stressed??Yes?NoDo you have problems with eating or your appetite??Yes?NoDo you cry frequently??Yes?NoHave you ever attempted suicide??Yes?NoHave you ever seriously thought about hurting yourself??Yes?NoDo you have trouble sleeping??Yes?NoHave you ever been to a counselor??Yes?NoWOMEN ONLYAge at onset of menstruation:Date of last menstruation:Period every _____ daysHeavy periods, irregularity, spotting, pain, or discharge??Yes?NoNumber of pregnancies _____ Number of live births _____Are you pregnant or breastfeeding??Yes?NoHave you had a D&C, hysterectomy, or Cesarean??Yes?NoAny urinary tract, bladder, or kidney infections within the last year??Yes?NoAny blood in your urine??Yes?NoAny problems with control of urination??Yes?NoAny hot flashes or sweating at night??Yes?NoDate of last PAP smear?Any abnormal PAP smears? If so, when?MEN ONLYDo you usually get up to urinate during the night??Yes?NoIf yes, # of times _____Do you feel pain or burning with urination??Yes?NoHas the force of your urination decreased??Yes?NoHave you had any kidney, bladder, or prostate infections within the last 12 months??Yes?NoDo you have any problems emptying your bladder completely??Yes?NoAny difficulty with erection or ejaculation??Yes?NoAny testicle pain or swelling??Yes?NoDate of last prostate cancer screening?OTHER PROBLEMSCheck if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.?Skin?Chest/Heart?Recent changes in:?Head/Neck?Back? Weight?Ears?Intestinal? Energy level?Nose?Bladder? ?Throat?Bowel?Other pain/discomfort?Lungs?Circulation?Stress/anxiety/feeling down ................
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