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Health Questionnaire

Please fill out the form completely, print, sign and remember to bring it to your office appointment

Name (Last, First, MI):      

Today’s date:      

FAMILY HISTORY:

Medical problems in your blood relatives: Please mark the appropriate space with M or F if that condition affected your mother or father, B or S if it affected your brother or a sister, C for child and GP for a grandparent:

  Gallstones   Ulcers   Diabetes   Arthritis   Celiac disease (Gluten allergy)

  Colon polyps   Colon cancer   Colitis/ Crohn’s disease   Irritable Bowel Syndrome

  Hemochromatosis (iron storage disease)   Hepatitis   Other liver diseases: What type:      

  Heart disease   High blood pressure   Cancer: What type      

  Depression   Genetic diseases: What type      

YOUR HEALTH HISTORY: Have you ever had any of these medical problems:

Colon polyps Colon Cancer Ulcerative colitis Crohn’s Gallstones Diverticulitis

Celiac disease (Gluten allergy) Ulcers Problems with excessive bleeding

Hepatitis Jaundice Other liver Problems:     

Pancreatitis Diabetes High blood pressure Heart attacks Rheumatic fever

Breathing difficulty Tuberculosis Sleep apnea Depression Arthritis

Cancer: What type:       Kidney stones Thyroid problems Stroke

Infections: What type:       Are you on Aspirin or other blood thinners? Which one:     

HAVE YOU HAD ANY SURGERIES:

Date What was done

           

           

           

           

           

HAVE YOU BEEN IMMUNIZED AGAINST ANY OF THE FOLLOWING:

Hepatitis A Hepatitis B Tetanus Mumps Flu shot

MEDICATIONS YOU ARE TAKING: (Include vitamins, herbs and other over-the-counter products):

Name of medication Strength How often taken Reason taken

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MEDICATIONS YOU ARE ALLERGIC TO:

I am not aware of any drug allergies.

Name of medication When did the reaction occur? What was the reaction?

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PHARMACY INFORMATION:

NAME OF THE PHARMACY YOU USE REGULARLY:       CITY:      

ADDRESS OR NEAREST CROSS STREET:       PHONE:      

HAVE YOU HAVE HAD ANY OF THE FOLLOWING TESTS:

When Results

Ultrasound            

CAT scan of the abdomen            

Colonoscopy            

Endoscopy of the stomach (EGD)            

SOCIAL HISTORY:

Place of Birth (include country if you were not born in the US):     

Current Occupation:      Have you been exposed to hazardous material?

Were you a smoker ever? If Yes: Age began      Age quit      Number of packs per day      Are you currently smoking:

Do you drink alcohol? If Yes: What kind?       How often?      

Do you drink sodas or coffee? Daily? If not daily then how often?      How many per day?      

Do you exercise: If Yes: How often:     What type of exercise:     

REVIEW OF SYMPTOMS: (Check where applicable for recent occurrence)

|Head and Neck: |Digestive System: |Female Reproductive System: |

| Frequent headaches | Problem swallowing |Last menstrual period:       |

| Neck pain | Heartburn |Last GYN exam:       |

| Neck lumps | Belching | Are you currently pregnant |

|Eyes : | Nausea | Do you have irregular periods |

| Change in vision | Vomiting | Heavy menstrual flow |

| Double vision | Vomiting blood | Vaginal discharge |

| Eye pain or redness | Bloating | Painful intercourse |

| See fixed spots | Black stools | Breast lumps |

|Ears: | Blood in the stools. |Skin: |

| Hearing difficulty | Constipation | Easy bruising |

| Ringing ears | Diarrhea | Change in color |

| Earache | Diverticulosis | Itching or burning |

| Discharge from ears | Hemorrhoids |Neurological: |

|Mouth: | Loss of appetite | History of seizures |

| Pain on chewing | Weight loss | Easy fainting |

| Bleeding gums | Blood transfusion | Tremors |

| Sore gums or mouth | Use of street drugs | Numbness in extremities |

| | Contact with hepatitis | Weakness in extremities |

| | | |

| | | |

|(CONTINUED) | | |

|Nose and throat: | | |

| Frequent nosebleeds | Jaundice | Backache |

| Change in voice | | |

| |Extremities: |Mood: |

| Nasal congestion | Swelling or redness of the joints | Difficulty relaxing |

|Respiratory: | Rash over the legs | Feel excessively stressed |

| Wheezing | Leg cramps | Suicidal ideas |

| Coughing phlegm |Urinary: | Desire psychiatric help |

| Coughing blood | Frequent urination at night | |

| Recent colds | Burning on urination | |

|Cardiovascular: | Urgency to urinate | |

| High blood pressure | Blood in the urine | |

| Irregular heartbeats | Difficulty starting urine stream | |

| Heart attacks |Male Reproductive System: | |

| Chest pain | Thin urine stream | |

| Shortness of breath | Lumps or pain in the testicle | |

Leg swelling Prostate problems ___________________________________________

Signature

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