Medical History Questionnaire

Office Use Only

Medical Office:

 

 

All questions in this questionnaire are strictly confidential. 
This questionnaire will take approximately 10 minutes to complete.

 

 

 

Today's Date             
Name (Last, First, M.I.)    Male Female
DOB (MM/DD/YY) Age  Height  Weight 

Are you taking this test for health screening purposes?

 Yes No  

What is your main health concern?

Personal Health History

Please describe any symptoms that you are currently experiencing:

Have you had a fever in the past 3 months? Yes No      

For women, is your menstrual period?

Regular Irregular Heavy I am menopausal
Check all health conditions that apply to you:

High Cholesterol Anemia   Digestive Disorders
High Blood Pressure
Heart Disease/Angina
Stroke		 Cancer
  Type          
  Treatment 		  Reflux/GERD
  Prostate Enlargement/BPH
  Pulmonary/Respiratory Disorders/Asthma
Allergies/Eczema Chronic Fatigue   Osteoporosis/Osteopenia
Thyroid Disease Type 1 Diabetes   Neurological Disorders
Autoimmune Disorder
   Type 		Type 2 Diabetes
Hepatitis		   Reproductive Disorders or Low Libido
  Major Depression
Rheumatoid Arthritis Gout   Anxiety

Arthritis/Osteoarthritis

    Other

Please describe any marked check boxes:

 

Medications

Prescribed (including birth control. steroid medications, hormone replacement therapy, and allergy shots):

 

Over the Counter:

 

Vitamins/Supplements:

 

Have you had any injections in the past month?

Yes No

If yes, what type?

Have you taken any steroids in the past month (e.g. testosterone, prednisone, cortisone, decadron)?
Yes No
Are you taking a medication to reduce stomach acid (e.g. Nexium, Prilosec)?
 Yes  No
Have you received a hepatitis immunization series?
 Yes  No

Surgeries and Hospitalizations

 

Surgeries and hospitalizations.  If you have had surgery in the past year, please indicate the month of the surgery.

Year Reason

If you have had a hysterectomy, were both ovaries removed?

Yes No N/A

If you have had a prostatectomy, did you have an orchiectomy (removal of testes)?

Yes No N/A

Lifestyle

Alcohol

Never Rarely Up to 2 per day > 2 per day

Tobacco

Never Quit for Years <1 pack/day >1 pack/day

Physical Activity

Sedentary Occasional Regular Athletic training or equivalent

Family History

Check all health conditions that have affected family members:
I am adopted Rheumatoid Arthritis  Digestive Disorders

High Cholesterol

 High Blood Pressure

 Heart Disease/Angina

Cancer

   Type          

   Treatment

 Prostate Enlargement/BPH

 Pulmonary/Respiratory Disorders/Asthma

 Osteoporosis/Osteopenia

  Stroke Type 1 Diabetes   Neurological Disorders
  Thyroid Disease  Type 2 Diabetes  Other

Autoimmune Disorder

  Type