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									                                             Medical History Questionnaire

Name: _________________________ Date____________Chart # _______ Marital Status: M S W D

Mailing Address: ___________________________________________________________________

Occupation ___________________________________ Phones: ____________________________

Allergies _________________________________________________________________________

Recent Vaccine Dates: Tetanus______Pneumonia______Flu______Hepatitis______Shingles_______MMR______Gardisil_______

 Family History – If any blood relative has the following, circle the number and indicate which relative.
    1. Epilepsy             6. Thyroid             11. Osteoporosis       16. Alcoholism
    2. Migraine             7. Hay Fever           12. Arthritis          17. Cancer
    3. Mental Illness      8. Asthma              13. Heart Disease           ________________________________
    4. Glaucoma             9. Anemia              14. Stroke                 ________________________________
    5. Diabetes            10. Bleeds easy         15. Hypertension           ________________________________


   Year            Hospitalization                Year              Hospitalization
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________

 Medical History: Mark “C” for current problems. List age when symptoms began.

 Main Problems: 1. ________________________ 2._________________________ 3. ________________________

  Decreased Hearing              Loss of Appetite                  Cancer                   Blood Exposure
  Ringing in Ear                 Difficulty swallowing             Diabetes                 Alcohol        oz. per week
  Ear Infection                  Indigestion/Heartburn             Thyroid Disease          Smoking         cigs per day
  Dizzy Spells                   Nausea & Vomiting                 Seizures/Convulsions     Coffee/Tea     cups per day
  Failing Vision                 Peptic Ulcers                     Stroke
  Double Vision                  Abdominal pain                    Tremor/Shaking Hands     HIV status-
  Eye Infections                 Gall Bladder Trouble              Muscle Weakness
  Nose Bleeds                    Jaundice/Hepatitis                Numbness/Tingling
  Sinus Trouble                  Bowel Habit Change                Headache
  Sore Throat                    Diarrhea/Constipation             Arthritis/Rheumatism                FEMALES:
  Hay fever/Allergies            Diverticulitis, Colitis           Back Pain                LMP date-
  Hoarseness                     Bloody/Tarry Stools               Bone Fracture/Injury     Last Pap date-
  Pneumonia/ Pleurisy            Hemorrhoids                       Gout/Osteoporosis        Last Mammo date-
  Bronchitis/Cough               Hernia                            Foot Pain/Numbness       Last Dexa date-
  Asthma/Wheezing                Urine infections                  Rashes/Hives             # of Pregnancies-
  Chest Pain                     Blood in urine                    Psoriasis/Eczema         # of Miscarriages-
  Shortness of Breath            Overnight urination > 3 times     Sleeping Difficulty      # of Abortions-
  High Blood Pressure            Urine, pain, flow, control loss   Nervousness/Depression   # of live births-
  Heart Murmur                   Kidney Stones                     Moodiness/Depression             Menstrual Flow:
  Irregular Pulse/Palpitations   Venereal Disease                  Phobias                    Regular
  Swollen Ankles                 Urethral discharge                Mental Illness             Irregular
  Fainting Spells                Chronic Fatigue                   Tuberculosis               Pain/Cramps
  Leg Pain – walking             Recent Weight Loss                Rheumatic Fever
  Varicose Veins/Phlebitis       Anemia/Bruise Easily              Scarlet Fever            Birth Control Method-
  Chicken Pox                    Polio                             Mumps

 Special Notes_______________________________________________________
 __________________________________________________________________
 __________________________________________________________________

								
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