Medical History Questionnaire Form Page 2
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3Last Name:_________________
Today’s Date: _____________
Present Health
(Check all those that apply. Write further comments below)
____High blood pressure (>140/90)
____Low blood pressure (<90-70)
____Chest pain at rest
____Leg cramps
____Thumping/racing of heart at rest
____Difficulty breathing
____Heart skips beats/extra beats
____Shortness of breath
____Ankles tend to swell
____Out of breath while lying/sitting
____High cholesterol (________)
____Chronic/recurring morning cough
____1 or more episodes of coughing up blood
____Anxiety/depression
____Chronic fatigue
____Difficulty sleeping
____Increased irritability
____Migraine/recurrent headaches
____Joints swollen, stiff, painful
____Back pain
____Leg pain after short walks
____Vision/hearing problems (__________)
____Recent change in mole or wart
____Men only: prostate problems
____Hands/feet often cold even in warm weather
____Stomach/GI distress (constipation, diarrhea, heartburn, ulcers, etc
Women Only (check all that apply)
____Currently pregnant (if yes: _____ weeks)
No. of pregnancies _______________
____Taking oral contraceptives
No. of children __________________
____Menstrual problems (comment below if yes)
Date of last menstruation _________
____Breast discharge/lumps
Comments:
Please indicate if you have had any history of the following conditions. If you check yes, comment
below:
____Heart attack
When?_____
____Arthritis in arms/legs
____Heart murmur
____Diabetes /abnormal blood sugar test
____Diseases of the arteries
____Thyroid problems
____Other heart problems
____Jaundice/gallbladder problems
____Stroke
When?_____
____Kidney/urinary problems
____Epilepsy/seizures (comment below)
____Polio
When?_____
____Varicose veins
____Blood clots
____Bronchitis
____Diphtheria
____Asthma
____Scarlet Fever
____Pneumonia
____Infectious Mononucleosis
____Other lung conditions
____Anemia
____Dizziness
____Nervous/emotional problems
____Chicken pox
____Measles
Comments:
List any other medical/diagnostic tests you have had in the past 5 years:
List any hospitalizations (include year and purpose):
Comment on any other medical conditions not mentioned in this questionnaire?
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Parent category: Life