Health History Form 1 My Information2 Medical History3 Medications & Allergies4 Family History5 Hospitalizations & Injuries6 Family Health History7 Habits & Occupation Name* First Last Email* Date of Birth* Date Format: MM slash DD slash YYYY Age*Please enter a number from 0 to 120.Sex*MaleFemaleDate of Last ExaminationReason for Visit Please check any conditions that you have.General Chills Depression Dizziness Fainting Fever Forgetfulness Headache Loss of Sleep Nervousness Numbness Sweats Muscle/Joint/Bone Arms Back Feet Hands Hips Legs Neck Shoulders Pain, weakness, numbness in:Genito-Urinary Blood in Urine Frequent Urination Lack of Bladder Control Painful Urination Cardiovascular Chest Pain High Blood Pressure Irregular Heartbeat Low Blood Pressure Poor Circulation Rapid Heartbeat Swelling of Ankles Varicose Veins Gastrointestinal Appetite Poor Bloating Bowel Changes Constipation Diarrhea Excessive Hunger Excessive Thirst Gas Hemorrhoids Indigestion Nausea Rectal Bleeding Stomach Pain Vomiting Vomiting Blood Eye, Ear, Nose, Throat Bleeding Gums Blurred Vision Cross Eyes Difficulty Swallowing Double Vision Earache Ear Discharge Hay Fever Hoarseness Loss of Hearing Nosebleeds Persistent Cough Ringing in Ears Sinus Problems Vision - Flashes Vision - Halos Blood Transfusions*YesNoHave you ever had a blood transfusion?Date of Last Blood Transfusion Date Format: MM slash DD slash YYYY Skin Bruise Easily Hives Itching Change in Moles Rash Scars Sore that Won't Heal Men Only Breast Lump Erection Difficulties Lump in Testicles Penis Discharge Sore Penis Other Men OtherWomen Only Abnormal Pap Smear Bleeding between periods Breast Lump Extreme Menstrual Pain Hot Flashes Nipple Discharge Painful Intercourse Vaginal Discharge Other Women OtherPregnanciesYearSexComplications List any pregnancies you have had. Use the plus icon (+) to add a new entry. Pharmacy NamePharmacy Phone NumberMedication List medications you are currently taking. Use the plus icon (+) to add a new entry.Allergies List all allergies. Use the plus icon (+) to add a new entry. RelativesRelationshipAgeState of HealthAge of DeathCause of Death List all immediate blood relatives (parents and siblings). Use the plus icon (+) to add a new entry. HospitalizationsYearHospitalReasonOutcome List all Hospitalizations. Use the plus icon (+) to add a new entry.InjuriesInjuryYearOutcome List all Injuries. Use the plus icon (+) to add a new entry. Blood Relative Health Issues Arthritis,Gout Asthma,Hay Fever Cancer Chemical Dependency Diabetes Heart Disease, Stroke High Blood Pressure Kidney Disease Tuberculosis Other Blood Relative Health Issues (Other)List condition and relatives with condition.Relatives with Arthritis,GoutList relatives with condition.Relatives with Asthma,Hay FeverList relatives with condition.Relatives with CancerList relatives with condition.Relatives with Chemical DependancyList relatives with condition.Relatives with DiabetesList relatives with condition.Relatives with Heart Disease, StrokeList relatives with condition.Relatives with High Blood PressureList relatives with condition.Relatives with Kidney DiseaseList relatives with condition.Relatives with TurberculosisList relatives with condition. Health Habits Caffeine Tobacco Drugs Other Other Health HabitFrequency of Caffeine UseFrequency of Tobacco UseFrequency of Drug UseFrequency of Other UseOccupationOccupational Concerns Stress Hazardous Substances Heavy Lifting Other Occupational Concerns (Other)ExerciseYesNoDo you exercise regularly?Type of ExerciseDietYesNoDo you follow a special diet?Type of DietOver the last 2 weeks, how often have you been bothered by any of the following problems?*Not at allSeveral daysMore than half the daysNearly every dayLittle interest or pleasure in doing thingsFeeling down, depressed, or hopelessTrouble falling or staying asleep, or sleeping too muchFeeling tired or having little energyPoor appetite or overeatingFeeling bad about yourself-or that you are a failure or have let yourself or your family downTrouble concentrating on things, such as reading the newspaper or watching televisionMoving or speaking so slowly that other people could have noticed. Or the opposite ? being so fidgety or restless that you have been moving around a lot more than usualThoughts that you would be better off dead, or of hurting yourself in some wayEmailThis field is for validation purposes and should be left unchanged.
