Health History Questionnaire

FAMILY PRACTICE HEALTH HISTORY QUESTIONNAIRE

Your answers on this form will help your health care provider better understand your medical
concerns and conditions. If you are uncomfortable with any question, do not answer it. If you
cannot remember specific details, please approximate. Add any notes you think are important.
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT
STRICTLY CONFIDENTIAL.

ALLERGIES
List anything that you are allergic to (medications, food, bee stings, etc.) and how each affects you.

ALLERGY
1. Grass
REACTION
hives, shallow breathing
2. trees
itchy eyes, stuffy/runny nose
3. cats & dogs
itchy eyes, stuffy/runny nose, hives
Art City Pharmacy

FAVORITE PHARMACY: __________________________________________________________
MEDICATIONS
Please list all the medications you are taking. Include prescribed drugs and over-the-counter drugs, i.e.,
vitamins and inhalers.
DRUG NAME
1. Zyrtec
STRENGTH
OTC
FREQUENCY TAKEN
2. Sudafed PE
3. Mucinex
10mg
q4h prn
400mg
4. Advil
200mg
q4h prn
2-4 q6-8h prn
Daily
5. Fish Oil
daily
6. calcium +D
daily
7. multi-vit
8.
daily
9.
10.
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IMMUNIZATION HISTORY
Immunizations and most recent date:
Chickenpox
Date:
Flu Shot
Date:
Gardasil/HPV
Date:
Hepatitis A
Date:
Hepatitis B
Date:
Meningococcus
x MMR (Measles, Mumps,
Rubella)
Pneumonia
Tdap (Tetanus and
pertussis)
Tetanus
Zostavax (Shingles)
(WOMEN ONLY) OBSTETRIC AND GYNECOLOGICAL HISTORY

Last PAP Smear
Date: 4/24/09 Abnormal
Last Mammogram
Date:
Abnormal
Age of First Menstrual Period 14
Last Period / Age of Menopause (Date / Age): 4/10 39
Number of pregnancies: 4
Number of Miscarriages: 1
Number of Cesarean sections: 0
Number of Births: 3
Number of Abortions: 0
x Male
Current sexual partner is:
Female
x No
Do you use condoms?
Yes
Other Birth control method used: no uterus

Interested in being screened for STDs:
Yes x No
Date: 6/15/88
Date:
Date:
Date:
Date:
CHECK BELOW IF APPLIES TO YOU:

Bleeding between periods
Heavy Periods
Extreme Menstrual Pain
Vaginal itching, burning, or
discharge
x Waking in the night to go to
the bathroom
x
Hot flashes
Breast lump or nipple
discharge
Painful intercourse
x Sexually Active
PAST MEDICAL HISTORY (Please check all that apply)

Anxiety Disorder
Diverticulitis
Arthritis
Fibromyalgia
x
Asthma
Gout
Bleeding Disorder
Has Pacemaker
Blood Clots
Heart Attack
Cancer
Heart Murmur
Coronary Artery Disease Hiatal Hernia or Reflux Disease
Claustrophobic
HIV or AIDS
Diabetes Insulin
High Cholesterol
Diabetes Non-Insulin
High Blood Pressure
Dialysis
Overactive Thyroid
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Date:
Kidney Disease
Kidney Stones
Leg/Foot Ulcers
x Liver Disease
Osteoporosis
Polio
Pulmonary Embolism
Reflux or Ulcers
Stroke
Tuberculosis
Other
PAST SURGICAL HISTORY

SURGERY
1. oblation
2. hysterectomy
3. Shoulder
REASON
polyps, heavy bleeding
YEAR HOSPITAL
2007 Union Hospital
endometriosis, bleeding
2010 AF Hospital
2012 AF Hospital
torn cartilidge
4.
5.
FAMILY HEALTH HISTORY
FATHER
MOTHER
BROTHER/SISTER
BROTHER/SISTER
OTHER:
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x
x
x
x
x
50
49
x
x
76
STROKE
OSTEOPOROSIS
GENETIC DISEASE
DIABETES
CANCER
DEPRESSION
ARTHRITIS
x
HYPERTENSION
Y
x N
Y
xN
Y
x N
Y
xN
xY
N
Y
xN
xY
N
xY
N
Y
N
HEART DISEASE
GRANDMOTHER
(MATERNAL)
GRANDFATHER
(MATERNAL)
GRANDMOTHER
(PATERNAL)
GRANDFATHER
(PATERNAL)
AGE
ALIVE?
RELATION
ALCOHOLISM
SIGNIFICANT HEALTH PROBLEMS IN MY FAMILY
x
x
SOCIAL HISTORY
EDUCATION
MARITAL STATUS
th
x Married Separated
< 8 grade
High School
2 Yr College
x 4 Yr College
Post Graduate
ALCOHOL
Drink Alcohol?
Yes
x
No
Single
Divorced
Widowed
Domestic Partner
EXERCISE
CAFFEINE
No exercise
x Occasional exercise
Moderate exercise
High level exercise
None
Occasional
x Moderate
Heavy
# cups/cans per day? ____
1-2
TOBACCO
DRUGS
Do you use Tobacco?

x
Yes No
Do you currently use recreational or

street drugs?
x If yes, please list:
Yes No
How often?
If not now, did you ever use tobacco?

x
Yes No
Cigarettes ____ pks./day
Occasionally
Chew ____ /day
< 3 times/week
Cigars ____/day
> 3 times/week
# Years Used ____
# Drinks/week? ____
Or year quit ____
ADDITIONAL HEALTH FACTS

Please add other information about your health that you would like your provider to know here:
Mirriam C Draper
PARENT, GUARDIAN OR CAREGIVER SIGNATURE
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4/1/2015
DATE

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FAMILY PRACTICE HEALTH HISTORY QUESTIONNAIRE

itchy eyes, stuffy/runny nose

3. cats & dogs

itchy eyes, stuffy/runny nose, hives

Art City Pharmacy

(WOMEN ONLY) OBSTETRIC AND GYNECOLOGICAL HISTORY

Other Birth control method used: no uterus

CHECK BELOW IF APPLIES TO YOU:

PAST MEDICAL HISTORY (Please check all that apply)

PAST SURGICAL HISTORY

FAMILY HEALTH HISTORY

SIGNIFICANT HEALTH PROBLEMS IN MY FAMILY

Do you use Tobacco?

Do you currently use recreational or

If not now, did you ever use tobacco?

Chew ____ /day

# Years Used ____

Or year quit ____

ADDITIONAL HEALTH FACTS

PARENT, GUARDIAN OR CAREGIVER SIGNATURE

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