All questions in this questionnaire are strictly confidential and will become part of your medical record.

__________________________________________________________________________________________________________________________________________________________________________________________________________
 

 Patient Last Name:
 First Name:
 MI:
Today's Date: ​​​​​​
​​
 
 

DOB:
 
Phone Number
 
 
 



PERSONAL HEALTH HISTORY (PAST MEDICAL HISTORY)

Conditions you have had in the past (check all that apply):
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Surgeries
 
 
 
 
Year
Reason
Hospital
Year
Reason
Hospital
Year
Reason
Hospital


Other hospitalizations
 
 
 
 
Year
Reason
Hospital
Year
Reason
 
Hospital
 
 
 
 
Have you ever had a blood transfusion?      
Do you know your blood type?                     
 
 


List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
 
 
 
 
Drug Name
Strength
Frequency Taken
Drug Name
Strength
Frequency Taken
Drug Name
Strength
Frequency Taken
Drug Name
Strength
Frequency Taken
Drug Name
Strength
Frequency Taken
Drug Name
Strength
Frequency Taken
Drug Name
Strength
Frequency Taken
Drug Name
Strength
Frequency Taken
Drug Name
Strength
Frequency Taken
Drug Name
Strength
Frequency Taken
Drug Name
Strength
Frequency Token
Drug Name
Strength
Frequency Token
Drug Name
Strength
Frequency Token
Drug Name
Strength
Frequency Taken


Allergies to medications
 
 
 
Drug Name
Reaction You Had
 
Drug Name 
Reaction You Had
 
Drug Name
 
Reaction You Had
 
Drug Name 
Reaction You Had
 



HEALTH HABITS AND PERSONAL SAFETY (SOCIAL HISTORY)

(All Questions Contained in this Questionnaire are Optional and will be Kept Strictly Confidential)

 
Exercise
 
 
 
 


Diet
 
 
 
 


Caffeine
 
 


Alcohol
 
 
 


Tobacco
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Drugs
 
 
 
 
 
 


Personal Safety
 
 
 
 
 
 
 

 
 
SOCIAL DETERMINANTS OF HEALTH

 
FAMILY HEALTH HISTORY
 
 
 
 
 
Father
Age
Age at Death
Significant Health Problems
Mother
Age
Age at Death
Significant Health Problems
Sibling
Age
Age at Death
Significant Health Problems
Sibling
Age
Age at Death
Significant Health Problems
Sibling
Age
Age at Death
Significant Health Problems
Sibling
Age
Age at Death
Significant Health Problems

 
 
MENTAL HEALTH QUESTIONNAIRE
 
 

 
SCREENINGS (please indicate most recent date)
 
 
 
 
 
 
 
 
 
 
  
 
REVIEW of SYSTEMS (check all that apply to you)

Contstitutional
 
 

 

Eyes

 

 
 
 


Ent/Mouth
 

 
 



Allergy/Immuno
 

 



Ent/Mouth
 

 



Psych
 



Endo
 

 



Skin
 

 
 
 



Genitourinary
 

 
 



Gastrointestinal
 

 
 



Hemp/Lymph
 

 



Respiratory
 

 



Cardiovascular
 

 



Musc/Skeletal
 

 
 
 



WOMEN ONLY
 

 
 
 
 
 
 
 
 
 
Experienced any recent breast tenderness, lumps, or nipple discharge?
 
 



MEN ONLY
 

Do you usually get up to urinate during the night?
 
 
 
 
Do you feel burning discharge from penis?
 
Has the force of your urination decreased?
 
Have you had any kidney, bladder, or prostate infections within the last 12 months?
 
Do you have any problems emptying your bladder completely?
 
Any difficulty with erection or ejaculation?
 
Any testicle pain or swelling?