ORIGINAL DATE: ___________________

DATES REVISED: ___________________

NEW PATIENT HEALTH HISTORY QUESTIONNAIRE

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

Name (Last, First, M.I.): M F DOB:

Marital Status: Single Partnered Married Separated Divorced Widowed
Previous or Referring Doctor:
PERSONAL HEALTH HISTORY
Childhood Illness: Measles Mumps Rubella Chickenpox Rheumatic Fever Polio
Immunizations & Dates: Tetanus Pneumonia
Hepatitis Chickenpox
Influenza MMR (Measles, Mumps, Rubella)
Main problems/reasons for this consulatation:

Additional problems or concerns you would like addressed:

NOTE: We may not be able to address every problem during the course of one consultation.

SURGERIES
YEAR REASON HOSPITAL

OTHER HOSPITALIZATIONS
YEAR REASON HOSPITAL

Have you ever had a blood transfusion? YES NO

Please list all of your prescribed medications, including over-the-counter medications such as vitamins and inhalers:
NAME OF MEDICATION STRENGTH DOSAGE/FREQUENCY

Please list any ALLERGIES TO MEDICATIONS:

NAME OF MEDICATION REACTION

1
HEALTH HABITS & PERSONAL SAFETY
All questions contained in this questionnaire are optional and will be kept strictly confidential.
EXERCISE: Sedentary (no exercise)
Mild Exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional Vigorous Exercise (i.e., work or recreation, less than 4x/week for 30 minutes)
Regular Vigorous Exercise (i.e., work or recreation, 4x/week for 30 minutes)
DIET: Are you dieting? YES NO
If YES, are you on a physician prescribed meal diet? YES NO
Number # of meals you eat in an average day?
Rank your SALT INTAKE High Medium Low
Rank your FAT INTAKE High Medium Low
CAFFEINE: None Coffee Tea Cola
Number # of Cups/Cans per Day? ___________
ALCOHOL: Do you drink alcohol? YES NO
If YES, what kind? ________________________
How many # drinks per week? ______________
Are you concerned about the amount you drinks? YES NO
Have you considered stopping? YES NO
Have you ever experienced blackouts? YES NO
Are you prone to “binge” drinking? YES NO
Do you drive after drinking? YES NO
TOBACCO: Do you use tobacco? YES NO
Cigarettes (pks/day) _________ Chew (#/day) ________ Pipe (#/day) _______ Cigars (#/day) _________
Number # of Years ______________ OR Year you Quit _________________
DRUGS: Do you currently use recreational street drugs? YES NO
Have you ever given yourself street drugs with a needle? YES NO
SEXUAL ACTIVITY: Are you sexually active? YES NO
If YES, are you trying for a pregnancy? YES NO
If not trying for pregnancy, list the contraceptive or barrier method used: _________________________________
Do you experience any discomft during intercourse? YES NO
Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk
factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your
provider about your risk of this illness? YES NO
PERSONAL Do you live alone? YES NO
SAFETY: Do you have frequent falls? YES NO
Do you have vision or hearing loss? YES NO
Do you have an Advance Directive and/or Living Will? YES NO
Would you like information on the preparation of these? YES NO
Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of
verbally treatening behavior or actual physical or sexual abuse.
Would you like to discuss this issue with your provider? YES NO

FAMILY HEALTH HISTORY

RELATIONSHIP AGE SIGNIFICANT HEALTH PROBLEMS RELATIONSHIP AGE SIGNIFICANT HEALTH PROBLEMS
FATHER CHILD
M F
MOTHER CHILD
M F
SIBLING CHILD
M F M F
SIBLING CHILD
M F M F
SIBLING GRANDMOTHER
M F (Maternal)
SIBLING GRANDFATHER
M F (Maternal)
SIBLING GRANDMOTHER
M F (Paternal)
SIBLING GRANDFATHER
M F (Paternal)
2
MENTAL HEALTH
Is stress a major problem for you? YES NO
Do you feel depressed? YES NO
Do you panic when stressed? YES NO
Do you have problems with eating or your appetite? YES NO
Do you cry frequently? YES NO
Have you ever attempted suicide? YES NO
Have you ever seriously thought about hurting yourself? YES NO
Do you have trouble sleeping? YES NO
Have you ever been to a counselor? YES NO

WOMEN ONLY
Age at onset of menstruation:
Date of last menstruation:
Period every __________ days
Do you have heavy periods, irregularity, spotting, pain, or discharge? YES NO
Number of pregnancies: ________________ Number of live births: _________________
Are you pregnant or breast feeding? YES NO
Have you had a D&C, hysterectomy, or Caesarean? YES NO
Any urinary tract, bladder, or kidney infections within the last year? YES NO
Any blood in your urine? YES NO
Any problems with control of urination? YES NO
Any hot flashes or sweating at night? YES NO
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period? YES NO
Have you experienced any recent breast tenderness, lumps, or nipple discharge? YES NO
What is the date of your last PAP and rectal exam? ___________________________

MEN ONLY
Do you usually get up to urinate during the night? YES NO
If YES, how many times/night? _____________________
Do you feel pain or burning when you urinate? YES NO
Is there any blood in your urine? YES NO
Do you feel burning discharge from your penis? YES NO
Has the force of your urination decreased? YES NO
Have you had any kidney, bladder, or prostate infections within the last 12 months? YES NO
Do you have any problems emptying your bladder completely? YES NO
Any difficulty with erection or ejaculation? YES NO
Any testicle pain or swelling? YES NO
What was the date of your last prostate and rectal exam? ___________________________

OTHER PROBLEMS
Please check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
Skin YES NO Chest/Heart YES NO Any recent changes in:
Head/Neck YES NO Back YES NO Weight YES NO
Ears YES NO Intestinal YES NO Energy Level YES NO
Nose YES NO Bladder YES NO Ability to Sleep YES NO
Throat YES NO Bowel YES NO Other Pain or Discomfort? YES NO
Lungs YES NO Circulation YES NO Explain: