Health Questionnaire

Date:

Month Day Year
Full Name: *

First Name Last Name
Birth Date: *

Month Day Year
Age:
Marital Status:

Single Married Separated Widowed Divorced
A. Medical Illnesses
Childhood Illnesses:

Chicken Pox Measles Mumps Rubella (German Measles) Rheumatic Fever Birth Abnormalities
Cardiovascular:

Heart Disease Heart Murmur High Blood Pressure Chest Pain Swelling Hands and Feet Palpitation Irregular Heartbeat Stroke High Cholesterol
Respiratory:

Lung Disease Asthma or Wheezing Chronic Cough Cough with Blood Difficulty Breathing Pneumonia Bronchitis Tuberculosis
Gastrointestinal

Intestinal Disease Gallbladder Disease Peptic Ulcer Liver Trouble Hepatitis Frequent Constipation Frequent Diarrhea Black Stools Blood in Stools Hemorrhoids Change in Bowel Habit Heartburn Abdominal Pain Vomiting
Hematologic:

Blood Disease Abnormal Bleeding Anemia Phlebitis Easy Bruising Sickle Cell Disease Blood Transfusion
Genitourinary:

Kidney Trouble Kidney Stones Loss of Urine Frequent Urination Nighttime Urination Painful Urination Blood in Urine
Endocrine:

Thyroid Disease Diabetes Heat/Cold lntolerance Weight Loss Difficulty Swallowing Recent Weight Change
Skin:

Skin Disease Jaundice Change/Skin Moles
ENT / Eyes:

Glasses Eye Disease Glaucoma Headaches Difficulty Hearing
Musculoskeletal:

Varicose Veins Joint Pains Back Pain Broken Bones Arthritis
Neuro-psychiatric:

Psychiatric Care Depression Convulsions Seizures Freq. Headaches
B. Surgical History
List types of surgery and dates performed:
C. Gynecological History
Date of Last PAP: *
Last Pelvic Exam: *
Last Mammogram: *
Menstrual History:
Age Period Started:
Days of flow:
Cycle length:
Are your cycles:

regular irregular
Amount of bleeding:

light average heavy
First day of last period: *
Sexual History:
Sexually active:

Yes No
Frequency of Intercourse:
Present birth control methods?
Previous birth control methods?
History high risk sexual contact (with IV drug users, bisexual, hemophiliac, multiple partners, etc.):

Yes No
Have you ever had any of the following?

Abnormal PAP DES exposures Bleeding between periods Herpes Gonorrhea Chlamydia Venereal warts Syphilis Frequent vaginal infections Painful periods Pelvic infection Pain with intercourse Heavy periods PMS Other Gynecological problems
D. Obstetrical History:
Total pregnancies:
Live birth:
Miscarriage:
Premature births:
Still birth:
Abortions:
Cesarean Sections:
Birth malformations:
Complications of pregnancies:

Preeclampsia Diabetes Bleeding
Other:
E. Social History:
Alcohol use:
Amount:
Tobacco use:
Amount:
Recreational drug use:
Employed?
Where and what type of work?
Disabled?
For how long and why?
F. Other:
I have had a colonoscopy:
When and what facility?
I have had a bone density test: *
When and what facility?
I have had Gardasil injections: *
#1 Date:
#2 Date:
#3 Date:
Do you wish to have (or have more) children in the future?
G. Family History

Check all that apply
High Blood Pressure:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Sister Brother Other
Heart Disease:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Sister Brother Other
Diabetes:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Sister Brother Other
High Cholesterol:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Sister Brother Other
Stroke:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Sister Brother Other
Blood Problems:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Sister Brother Other
Psychiatric Care:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Sister Brother Other
Breast Cancer? (Check all that apply):

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Sister Brother Other
Ovarian Cancer? (Check all that apply):

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Sister Brother Other
Other Cancer? Please list family member and cancer type, one per line.
Reason for your visit today?
Referred by:
Primary Care Provider:
Medication, Allergy & Provider List
Primary Pharmacy:
*The information provided below is correct to the best of my knowledge and I authorize Specialty Care & Surgery Center to access my medication history. Use mouse to sign your name below: *

Use the mouse to sign your name Clear
Medications

List all medications you are taking:

	Medication Name Include Herbs, Supplements & Vitamins	Medical Condition	Dosage	Directions	Start Date	End Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Allergies
Enviromental:

Yes No
Food Allergy Type:
Allergies to Medications:

Yes No
If Yes, name and reaction to them:
Please list current Providers including Primary care and Specialists
Provider Name:
Specialty:
City:
Provider Name:
Specialty:
City:
Provider Name:
Specialty:
City:
Patient Portal Access
We invite you to sign up for our patient portal for electronic access with our office. The benefits of patient portal include:
- Requesting appointment/cancelation
- Refill on medications
- Update on labs, visits or results
- Update on account balance
By clicking the yes option below, you are consenting to receive results via the Patient Portal.
Yes, Sign Me Up No thanks
Email address for Patient Portal:
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Should be Empty:

A. Medical Illnesses

B. Surgical History

C. Gynecological History

D. Obstetrical History:

E. Social History:

F. Other:

G. Family History

Medication, Allergy & Provider List

Medications

Allergies

Please list current Providers including Primary care and Specialists

Patient Portal Access