Richmond University Medical Center



INITIAL HISTORY QUESTIONNAIREName: ______________________________________Date: _______________Have you experienced any of the conditions/symptoms listed below?YesNoCardiovascular__________Heart attack__________Stroke__________High blood pressure__________Heart murmur__________Shortness of breath with exertion__________Valvular problems__________Chest pain__________Varicose veins/venous stasis__________Phlebitis__________Pulmonary embolus__________Respiratory:Chronic cough__________Emphysema__________Asthma__________Sleep apnea__________Wheezing__________TB__________GastrointestinalHiatal hernia__________Heart burn/reflux__________Stomach ulcers__________Gallbladder disease/gallstones__________Chronic constipation__________Chronic diarrhea__________Blood with bowel movement__________Previous abdominal surgery__________Difficulty swallowing__________Hernias__________YesNoJaundice__________Liver disease/hepatitis__________Gynecological:Pregnancies__________Irregular menstrual cycle__________Premenstrual bloating/cramping__________Infertility__________Abnormal pap smear__________Endocrine:Diabetes__________Diabetes treatment (diet/pills/insulin)__________High cholesterol/triglycerides__________Thyroid problems__________Musculo-skeletal:Arthritis__________Joint pain/joint stiffness__________Gout__________Difficulty walking__________Back problems__________Limitation of movement__________Weakness__________Psychosocial:Psychiatric problems__________Depression__________Mood changes__________Hallucinations__________Disorientation__________Seizures__________Eating disorders__________Disabled__________Neurologic:Numbness/tingling__________Fainting/blackouts__________Dizziness__________Tremors__________Headaches__________Urologic:Prostate problems__________Please answer the following:YesNoDo you smoke (if yes, how much?)__________Do you drink regular coffee (if yes, how much?)__________Do you drink regular soda (if yes, how much?)__________Do you eat candy/other sweets on a regular basis?__________Do you drink alcohol daily?__________Do you eat or snack after 8pm?__________Do you eat when you are not hungry or when stressed?__________Are you able to exercise? Is so, how often?__________Do you need to sleep on more than one pillow to breathe?__________Do you suffer with intestinal cramps, gas pains, fatty foodIntolerance, indigestion, heartburn?__________Do you have hemorrhoids or other rectal problems?__________Do you have a history of heart disease or high blood pressure?__________Do you have breathing problems with exertion?__________Do you have any circulation problems in your legs?__________Do you have large varicose veins?__________Do your feet, ankles, knees, hips ache and/or swell?__________Do you have significant back pain?__________Do you get up at night to urinate?__________Do you leak urine when you strain, cough, sneeze or lift?__________If you still have periods, are they regular?__________Do you use birth control? What kind?__________Do you use hormones? What kind?__________Do you have any sleep problems? What kind?__________Do you have any respiratory problems? What kind?__________When was your last chest x-ray?____________ yearWhen was your last rectal exam?____________ yearWhen was your last EKG?____________ yearYesNoHave you ever tried Weight Watchers, OA, Optifast, Slimfast,Atkins, fasting, Phen-fen physician supervised diet, other?(please circle)__________What is the most weight you ever lost at one time?____________ lbs.How long did you keep off that weight before regaining?____________ mos.How old were you when you first became seriously overweight?____________ ageDo you have a history of an eating disorder?__________ Past, Present, No history (please circle)Do you make yourself vomit, abuse laxatives or water pills__________Have you ever been abused?__________ sexually, verbally, emotionally, physically (please circle)__________Do you have a family history of heart disease?__________Do you have a family history of diabetes__________Do you have a family history of cancer?__________Have you seen any physicians in the last 5 years?__________ When? What for?THANK YOU FOR ANSWERING THIS LENGHTY QUESTIONNAIRE!!!ANWERING THESE QUESTIONS HELPS US TO HELP YOU BETTER.3/09 bmb ................
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