Health History Questionnaire Form (Page 2 of 2) in pdf

Please list the last year

in which you have had any of the following:

Physical Exam _______

Sigmoidoscopy/Colonoscopy (circle which one) ________ Cholesterol ________

Pap Smear __________

Stool Cards for Colon Cancer ________

Dental Visit _______

Mammogram ________

Rectal/Prostate Exam ________

Eye exam _________

Testicular Exam______

Bone Density___________

Stress Test________

Please list the last year

in which you have had any of the following.

Tetanus ________ Pneumonia shot ________ Hepatitis B series ________

Flu shot ________ PPD (TB test) ________

Measles, Mumps, Rubella (MMR) ________

Please describe your use of tobacco products.

 None

 Cigarettes

 Smokeless Tobacco

 Pipe  Cigars

How much do you or did you smoke ______ per day? For how many years ______?

Do you wish to quit?  Now  Soon  Eventually  Never

Have you quit? ________ When? _____________

How much alcohol do you drink weekly on average? __________________________________

Do you have a problem with alcohol?  Yes

 No

Have you used illicit drugs (marijuana, heroin, cocaine, LSD, etc)?  Yes

 No

How much caffeine do you drink daily (include coffee, tea, colas)? __________________________________

Are you sexually active? _____ Are your partners male, female, or both? (circle)

Do you use contraception?  None  Rhythm

 Condoms  Pill  Vasectomy IUD Diaphragm

 Tubal Ligation

 Never  Sometimes  Always

Do you practice safe sex?

Have you ever had a blood transfusion?  Yes

 No if Yes, what year ________?

What is your marital status?  Single  Married  Separated  Divorced  Widowed  Partner

Are you currently...  Employed  Unemployed  Self Employed  Retired

What is or was your occupation? _____________________________________________________

Please check which of the following behaviors you follow.

 Wear seatbelt

 Wear helmet while riding bike or motorcycle

 Smoke detector in house

 Fire Extinguisher in house

 Perform Self-Breast Exam Regularly

 Perform Self Testicular Exam

 Living Will or Advanced Directive  Frequent exposure to animals (cats, dogs, other)  Low Fat diet

 Exercise more than 3 times per week  Gun in House

Gun secured by lock

Please check if there is a history of any of the following diseases in your family.

 Heart Disease

 Diabetes

 Colon Cancer

Osteoporosis

Prostate Cancer

 Breast Cancer

 Ovarian Cancer

 High Cholesterol

 Skin Cancer

Please fill in the following family history.

Age (or age at death)

Medical Problems

Father _____________________________________________________________________________________

Mother _____________________________________________________________________________________

Siblings ____________________________________________________________________________________

___________________________________________________________________________________________

Children _____________________________________________________________________________________

____________________________________________________________________________________________

Patient Signature ______________________________________ Date _________________

Physician Signature ____________________________________ Date _________________

Health History Questionnaire Form Page 2

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