Health Questionnaire

Date:

MonthDayYear
Full Name:*

First NameLast Name
Birth Date:*

MonthDayYear
Age:
Marital Status:

SingleMarriedSeparatedWidowedDivorced
A. Medical Illnesses
Childhood Illnesses:

Chicken PoxMeaslesMumpsRubella (German Measles)Rheumatic FeverBirth Abnormalities
Cardiovascular:

Heart DiseaseHeart MurmurHigh Blood PressureChest PainSwelling Hands and FeetPalpitationIrregular HeartbeatStrokeHigh Cholesterol
Respiratory:

Lung DiseaseAsthma or WheezingChronic CoughCough with BloodDifficulty BreathingPneumoniaBronchitisTuberculosis
Gastrointestinal

Intestinal DiseaseGallbladder DiseasePeptic UlcerLiver TroubleHepatitisFrequent ConstipationFrequent DiarrheaBlack StoolsBlood in StoolsHemorrhoidsChange in Bowel HabitHeartburnAbdominal PainVomiting
Hematologic:

Blood DiseaseAbnormal BleedingAnemiaPhlebitisEasy BruisingSickle Cell DiseaseBlood Transfusion
Genitourinary:

Kidney TroubleKidney StonesLoss of UrineFrequent UrinationNighttime UrinationPainful UrinationBlood in Urine
Endocrine:

Thyroid DiseaseDiabetesHeat/Cold lntoleranceWeight LossDifficulty SwallowingRecent Weight Change
Skin:

Skin DiseaseJaundiceChange/Skin Moles
ENT / Eyes:

GlassesEye DiseaseGlaucomaHeadachesDifficulty Hearing
Musculoskeletal:

Varicose VeinsJoint PainsBack PainBroken BonesArthritis
Neuro-psychiatric:

Psychiatric CareDepressionConvulsionsSeizuresFreq. 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:

regularirregular
Amount of bleeding:

lightaverageheavy
First day of last period:*
Sexual History:
Sexually active:

YesNo
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.):

YesNo
Have you ever had any of the following?

Abnormal PAPDES exposuresBleeding between periodsHerpesGonorrheaChlamydiaVenereal wartsSyphilisFrequent vaginal infectionsPainful periodsPelvic infectionPain with intercourseHeavy periodsPMSOther Gynecological problems
D. Obstetrical History:
Total pregnancies:
Live birth:
Miscarriage:
Premature births:
Still birth:
Abortions:
Cesarean Sections:
Birth malformations:
Complications of pregnancies:

PreeclampsiaDiabetesBleeding
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:

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherSisterBrotherOther
Heart Disease:

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherSisterBrotherOther
Diabetes:

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherSisterBrotherOther
High Cholesterol:

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherSisterBrotherOther
Stroke:

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherSisterBrotherOther
Blood Problems:

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherSisterBrotherOther
Psychiatric Care:

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherSisterBrotherOther
Breast Cancer? (Check all that apply):

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherSisterBrotherOther
Ovarian Cancer? (Check all that apply):

MotherFatherMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherSisterBrotherOther
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:

YesNo
Food Allergy Type:
Allergies to Medications:

YesNo
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 UpNo thanks
Email address for Patient Portal:
Enter the message as shown*
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