Name:(Last, First, M.I.) 
PRESENT MEDICAL HEALTH CONCERN(S)

M F DOB: _____/_____/_____ 

Date: _____/_____/_____ 
HEALTH HISTORY QUESTIONNAIRE 
All questions contained in this questionnaire are strictly confidential and will become part
of your medical record. 

Please describe your current medical problem(s) and why you are seeking consultation. 
ILLNESSES (Check all that apply)
Have you ever been diagnosed with any of the following illnesses or medical problems? If yes, include
approximate date or year. 

High Blood Pressure 
Coronary Artery Disease 
Heart Attack 
Angina
Heart Failure 
Mitral Valve Prolapse
Heart Attack 
Angina
Cerebrovascular Accident (Stroke) 
Diverticulosis/Diverticulitis 
Gout 
Depression 
Cardiac Arrhythmia
Heart Murmur 
Abdominal Aortic Aneurysm 
Pulmonary Tuberculosis 
High Cholesterol 
Paget’s Disease 
Anemia 
Leukemia 
Cervical Cancer 
Ovarian Cancer 
Breast Cancer 
Bladder Cancer 
Prostate Cancer 
Testis Cancer 
Kidney Stones
Urinary Incontinence 
Prostate Enlargement (BPH)
Other 

Date/Yr: Asthma/Bronchitis Date/Yr: 
Date/Yr: Emphysema Date/Yr:
Date/Yr: Multiple Sclerosis Date/Yr:
Date/Yr: Parkinson’s Disease Date/Yr: 
Date/Yr: Alzheimer’s Disease Date/Yr: 
Date/Yr: Heart Valve Replacement/Repair        Date/Yr:
Date/Yr: Seizures Date/Yr:
Date/Yr: Thyroid Disease Date/Yr:
Date/Yr: Diabetes Date/Yr:
Date/Yr: Hiatal Hernia Date/Yr:
Date/Yr: Glaucoma Date/Yr:
Date/Yr: HIV/AIDS Date/Yr:
Date/Yr: Transient Ischemic Attack (TIA) Date/Yr:	
Date/Yr: Deep Venous Thrombosis Date/Yr:
Date/Yr: Pacemaker       Date/Yr:
Date/Yr: Hepatitis Date/Yr:
Date/Yr: Gallstones     Date/Yr:
Date/Yr: Ulcerative Colitis Date/Yr:
Date/Yr: Osteoarthritis Date/Yr:
Date/Yr: Colon Cancer Date/Yr:
Date/Yr: Cardiac Catheterization                       Date/Yr:
Date/Yr: Hodgkin’s Disease Date/Yr:
Date/Yr: Malignant Lymphoma Date/Yr:
Date/Yr: Lung Cancer Date/Yr:
Date/Yr: Kidney Cancer Date/Yr:
Date/Yr: Cardiac Stents                                    Date/Yr:
Date/Yr: Angioplasty                      Date/Yr:
Date/Yr: Urinary Tract Infection Date/Yr:
Date/Yr: Defibrillator                                           Date/Yr:

Surgery
MEDICATIONS 

Diagnosis Date/Yr.

OPERATIONS
Please list all surgeries including approximate date or year. 

Please list your prescribed drugs and over-the-counter drugs, such as vitamins and nutritional 
supplements including approximate start date. 

Name of Drug 
ALLERGIES

Strength Frequency Taken Start Date/Yr. 

Please list all drug allergies including type of reaction.
Drug Type Reaction
PERSONAL HISTORY AND HEALTH HABITS
Marital Status
Religion
Occupation 
Physical Activity 
Dietary 

Married 
Non-Ambulatory 
Walking 
Aerobic Training 
Other 
Regular 
Low Fat 
Vegetarian 
Other 

Single Divorced
Limited-Mobility
Running

Separated 

Widow 
Inactive 
Swimming
Recreational Activities
Weight Reduction 
Weight Gain 
Lactose Free 

Strength Training 
Diabetic
Renal Failure
Gluten Free

None 
None 
Beer (drinks/wk): __________ 
Wine (drinks/wk): _________ 
Liquor (drinks/wk) : ________ 
None 
Cigarette (pks/day): _______
Cigar (#/day): ____________
Pipe (#/day): _____________ 
Chew (#/day): ____________
Snuff (#/day): ____________ 
None 
Marijuana (#/day): _________ 
Cocaine (#/day): __________
Other (#/day): ____________ 

Living Will Surrogate
Duration: ________ years Date Discontinued: _________ 
Duration: ________ years Date Discontinued: _________ 
Duration: ________ years Date Discontinued: _________ 
Duration: ________ years Date Discontinued: _________ 
Duration: ________ years Date Discontinued: _________ 
Duration: ________ years Date Discontinued: _________ 
Duration: ________ years Date Discontinued: _________ 
Duration: ________ years Date Discontinued: _________ 
Duration: ________ years Date Discontinued: _________ 
Duration: ________ years Date Discontinued: _________ 
Duration: ________ years 	 Discontinued: _________ 
Advance Directive
Alcohol
Tobacco 
Drugs 

FAMILY HEALTH HISTORY
No History of Familial Disease 
Relative (i.e., Father, Mother, Uncle, Sister, etc.)
REVIEW OF SYSTEMS (Check all that apply) 

Illness (i.e., Diabetes, Heart Disease, Prostate Cancer, etc.)

General 
Eyes 
Ears, Nose, and Throat 
Cardiovascular 
Respiratory
Gastrointestinal 
Genitourinary

Anorexia
Fever 
Weight Loss
Blurred Vision 
Eye Discharge
Decreased Hearing
Hoarseness 
Chest Pain 
Palpitations
Cough
Shortness of Breath
Abdominal Pain 
Diarrhea
Bloody Stools 
Painful Urination 
Difficulty Voiding

Chills 
Malaise 
Double Vision 
Vision Loss 
Ringing in Ears 
Pain with Swallowing 
Peripheral Edema 
Wheezing 
Nausea 
Constipation 
Blood in Urine 
Urinary Incontinence 

Fatigue
Sweats 
Eye Pain
Eye Irritation 
Ear Pain 
Nose Bleeds
Bloody Sputum
Vomiting
Tarry Stools 
Sexual Dysfunction

Musculoskeletal 
Skin 
Neurological
Psychiatric 
Endocrine 
Hematologic and
Lymphatic 
Allergic and 
Immunologic 
CERTIFICATION

Back Pain
Muscle Weakness 
Dryness 
Suspicious Lesion
Dizziness
Seizures 
Depression 
Hallucinations 
Cold Intolerance
Weight Change 
Abnormal Bruising
Hay Fever

Joint Pain Joint Swelling
Itching Rash
Weakness Tremors 
Anxiety Memory Loss
Heat Intolerance Increased Thirst 
Easy Bleeding Enlarged Lymph Nodes
Itching HIV Exposure 
The above information is true to the best of my knowledge.
X
Patient/Legal Guardian/Authorized Person (Signature) Date of Signature