Health History Questionnaire Form printable pdf download

HEALTH HISTORY QUESTIONNAIRE

Date _______________________ Name____________________________________ DOB___________________

Please answer every question on both sides of the following pages.

Please check any of the following medical problems that you have had.

Abn. Weight Loss

Rheumatic Fever

Arthritis or joint pain

Abnormal Pap smear

Abn. Weight Gain

High Cholesterol

Gout

Abnormal Mammogram

Excessive Fatigue

Heart Failure

Broken Bones

Breast Lump

Insomnia

Heart Attack

___#Pregnancies

Anemia

High Blood Pressure

Rashes

___ Live Births

Cancer or Tumor

Hives

___ Miscarriages

Breathing Problems

Moles

___ Abortions

Glasses/ Contacts

Frequent Bronchitis

Glaucoma

Emphysema

Seizure

Have you been exposed

Cataracts

Pneumonia

TIA

to or do you have a

Other Problems with vision

Asthma

Stroke

close family member

Numbness

with...

Hearing Loss

Heartburn

Weakness

Ear Problems

Ulcer Disease

Memory Loss

HIV/AIDS

Ringing in Ears

Gallbladder Disease

Headaches

Hepatitis

Blood in Stool

TB

Allergies

Hepatitis

Depression

Frequent Sinus Infections

Diarrhea, Constipation, or

Anxiety/ Panic Attacks

Suicide Attempt

other changes in bowel habits

Dentures

Hemorrhoids

Physical Abuse

Dental Problems

Abdominal Pain

Sexual Abuse

Recurrent Sores in Mouth

Colon Polyp

Mental Illness

Angina

Urinary Frequency

Diabetes

Frequent Chest Pain

Bladder Infections

Thyroid Disease

Irregular Heartbeat

Prostate Problems

Sexually Transmitted Diseases

Heart Murmur

Urinary Incontinence

Kidney Problems

Health History Questionnaire Form

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