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Health History QuestionnaireAll questions contained in this questionnaire are strictly confidential and will become part of your medical record.Patient Last Name _________________________ First Name _________________________ Date of Birth ____________Medication ListList your prescribed drugs, inhalers and over-the-counter drugs and vitamins Name of DrugStrengthFrequencyAllergies to medicationsName of DrugReaction SurgerySurgeryYearChronic Health Problems check all that apply?Allergies?Anemia?Anxiety?Arthritis?Asthma?Blood Clots ?Cancer______________? Seizures?COPD?Congestive Hearth Failure?Sleep Apnea?Crohns/Colitis?Depression?Diabetes?Gallbladder disorder?GERD/Acid Reflux?Headaches/Migraine?Heart Disease?Heart Attack?Hypertension?Irritable Bowel Syndrome ?Kidney Disease ?Osteoporosis?other_____?Stroke?Thyroid Disorder?other_________?other_________Family Health History:List all health problems each experienced and indicate if deceased, the age and cause of death.Age CauseMother_______________________________________________________________Father________________________________________________________________Paternal Grandmother___________________________________________________Paternal Grandfather____________________________________________________Maternal Grandmother__________________________________________________Maternal Grandfather___________________________________________________Siblings_______________________________________________________________Other________________________________________________________________Health Maintenance:Flu Vaccine: ?Yes ?No Date________Tetanus Vaccine:?Yes ?No Date________Shingles Vaccine:?Yes ?No Date________Pneumonia Vaccine: Type________ ?Yes ?No Date of Dose #1______ Dose #2_____Complete Physical Exam: ?Yes ?No Date________Adults over 20 Cholesterol: ?Yes ?No Date________Adults over 50 Colonoscopy: ?Yes ?No Date________Females over 21 Pap Smear: ?Yes ?No Date________Females over 50 Mammogram: ?Yes ?No Date________Females over 65 Bone Density Scan: ?Yes ?No Date________Males over 50 Prostate Exam:?Yes ?No Date________Specialist:Doctor’s Name Specialty Contact Information________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Health Habits and Safety:Do you have a living will or advance directives? ?Yes ?NoDo you currently use recreational or street drugs? ?Yes ?NoHave you ever given yourself street drugs with a needle? ?Yes ?NoDo you eat a healthy diet and exercise regularly?????Yes ?NoIf you are over the age of 65, do you experience frequent falls? ?Yes ?No ?N/AAre you sexually active? ?Yes ?NoIf yes, are you trying for a pregnancy? ?Yes ?No If not trying for a pregnancy list contraceptive or barrier method used: ______________Do you fear for your safety or have a history of abuse? ?Yes ?NoCaffeine ? None ?Coffee ?Tea ?Cola _____ # of cups per day?Alcohol Do you drink alcohol? ?Yes ?NoIf yes, what kind?___________ Amount and frequency______________Are you concerned about the amount you drink? ?Yes ?No Tobacco ? Current Smoker ? Former Smoker ? Never Smoker ? Vape???Cigarettes – pks./day____ ?Chew - #/day____ ?Pipe - #/day____ ?Cigars - #/day____? Vaping___Year Started ______ Year Quit ______. Tried to quit? ?Yes ?NoPrevious MD_______________ Last Seen:_______________Primary Pharmacy: ______________________________________ Location:_______________Secondary Pharmacy: ____________________________________ Location: _______________Signature: _____________________________________________________ Date: _______________________________ ................
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