Health Information Questionnaire

Health Information Questionnaire
Your answers to the following questions will help us to understand your medical history and the concerns you would like to discuss with the doctor. Please fill out as much of this questionnaire as possible. If you cannot answer some of the questions or feel uncomfortable answering them, please leave them blank. Thank you for your help.
Note: All new patients must contact the office to schedule an appointment.
Patient Name*
Patient Date of Birth*

MonthDayYear
Phone Number*
Today's Date

MonthDayYear
What would you like to talk to the doctor about today?
Medical History
Please check to indicate if you have ever had the following conditions:

DiabetesHigh Blood PressureHeart AttackAsthmaKidney DiseaseHepatitisThyroid DiseaseSeizureStrokeDepressionEmphysemaTuberculosisArrhythmiaCoronary Artery DiseaseCongestive Heart FailureHigh CholesterolCancerOther
What kind/s of cancer?
Other (please specify)
Please list any surgeries or hospital stays you have had and the approximate date/year:
Surgery #1
Date of Surgery #1

MonthDayYear
Surgery #2
Date of Surgery #2

MonthDayYear
Surgery #3
Date of Surgery #3

MonthDayYear
If you have any other medical problems or serious injuries that are not listed above, please describe them here:
Please name any drugs you are allergic to:
What pharmacy do you use?
Pharmacy Phone Number
Please list all medications you are taking, including vitamins, natural supplements, and prescription medications.
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Are you currently receiving care from any other doctors, chiropractors, or other health care professionals? If yes, we would like to know whom so that we can coordinate your care:
Provider #1
Provider #2
Provider #3
Provider #4
If you have had any of the following tests performed, please note when the tests were done:
Cholesterol
Results
Pap Smear
Results
Mammogram
Results
Colonoscopy
Results
Tetanus
Pneumonia
Influenza
Hepatitis B
Other (please specify)
Other (please specify)
Health Habits
Do you smoke or use tobacco products?

YesNoQuit
If yes, number of cigarettes each day?
For how many years?
Do you drink beer, wine, or another type of alcohol?

YesNoQuit
If yes, how much?
How often?
Do you exercise on a regular basis?

YesNo
If yes, how often?
Do you currently drink coffee and/or tea?

YesNo
If yes, how many cups per day?
Do you wear a seatbelt while driving?

YesNo
What is your occupation?
Family History

Please include any history of Diabetes, Cancer, Heart Disease, Stroke, Blood Disorders, High Blood Pressure, or any history of Mental Illness
Mother's name
Is your mother living?

YesNo
Age at death
Please list all serious illnesses your mother has or had
Father's name
Is your father living?

YesNo
Age at death
Please list all serious illnesses your father has or had
1st sister's name
Is your 1st sister living?

YesNo
Age at death
Please list all serious illnesses your 1st sister has or had
2nd sister's name
Is your 2nd sister living?

YesNo
Age at death
Please list all serious illnesses your 2nd sister has or had
3rd sister's name
Is your 3rd sister living?

YesNo
Age at death
Please list all serious illnesses your 3rd sister has or had
1st brother's name
Is your 1st brother living?

YesNo
Age at death
Please list all serious illnesses your 1st brother has or had
2nd brother's name
Is your 2nd brother living?

YesNo
Age at death
Please list all serious illnesses your 2nd brother has or had
3rd brother's name
Is your 3rd brother living?

YesNo
Age at death
Please list all serious illnesses your 3rd brother has or had
Paternal grandfather's name
Is your paternal grandfather living?

YesNo
Age at death
Please list all serious illnesses your paternal grandfather has or had
Paternal grandmother's name
Is your paternal grandmother living?

YesNo
Age at death
Please list all serious illnesses your paternal grandmother has or had
Maternal grandfather's name
Is your maternal grandfather living?

YesNo
Age at death
Please list all serious illnesses your maternal grandfather has or had
Maternal grandmother's name
Is your maternal grandmother living?

YesNo
Age at death
Please list all serious illnesses your maternal grandmother has or had
Any other significant family history not mentioned above?
By signing below, I hereby certify that to the best of my knowledge, all the information I have furnished on this form is complete, true, and accurate.
Patient/Legal Guardian Signature*

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MonthDayYear
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Health Information Questionnaire

Medical History

Health Habits

Family History