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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 |
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|(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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