Health History Form 1My Information2Medical History3Medications & Allergies4Family History5Hospitalizations & Injuries6Family Health History7Habits & Occupation Name* First Last Email* Date of Birth* MM slash DD slash YYYY Age*Please enter a number from 0 to 120.Sex* Male Female Date of Last Examination Reason 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* Yes No Have you ever had a blood transfusion?Date of Last Blood Transfusion 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 Other Women Only Abnormal Pap Smear Bleeding between periods Breast Lump Extreme Menstrual Pain Hot Flashes Nipple Discharge Painful Intercourse Vaginal Discharge Other Women Other PregnanciesYearSexComplications List any pregnancies you have had. Use the plus icon (+) to add a new entry. Pharmacy Name Pharmacy Phone Number Medication 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,Gout List relatives with condition.Relatives with Asthma,Hay Fever List relatives with condition.Relatives with Cancer List relatives with condition.Relatives with Chemical Dependancy List relatives with condition.Relatives with Diabetes List relatives with condition.Relatives with Heart Disease, Stroke List relatives with condition.Relatives with High Blood Pressure List relatives with condition.Relatives with Kidney Disease List relatives with condition.Relatives with Turberculosis List relatives with condition. Health Habits Caffeine Tobacco Drugs Other Other Health Habit Frequency of Caffeine Use Frequency of Tobacco Use Frequency of Drug Use Frequency of Other Use Occupation Occupational Concerns Stress Hazardous Substances Heavy Lifting Other Occupational Concerns (Other) Exercise Yes No Do you exercise regularly?Type of Exercise Diet Yes No Do you follow a special diet?Type of Diet Over 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 wayNameThis field is for validation purposes and should be left unchanged.
