Patient Questionnaire

PATIENT QUESTIONNAIRE

Instructions: Please answer all questions to the best of your ability. Check all questions asking yes or no answers appropriately, but leave blank if you are not sure. Leave Comments column blank as these will be filled in by the providers.

DATE*

Name*

First NameLast Name

Email*

ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

A. GENERAL HEALTH (Select one)*

ExcellentGoodFairPoor

B. PAST MEDICAL HISTORY:*

	Yes	No	Year	Complications
Cancer
Diabetes
Blood Disorders
Heart Disease
Kidney Disease
High Blood Pressure
Liver Disease
Glandular Disorders
Skin Disease
Neurologic Disorders

OTHER ILLNESSES AND/OR SURGERY: (Please list illness or surgery, year, and complications)

	Illness or Surgery	Year	Complications

ALLERGIES: (List all drugs or substances to which you are allergic and specify type of reaction (i.e. itching, rash, hives, wheezing, swelling, etc)

	Allergy	Reaction

HABITS:*

	Yes	No	How much (per day/per week)
Cigarettes/Cigars/Pipe
Alcohol
Drugs (Specify)

CURRENT MEDICATIONS: List all medications and supplements which you take regularly

	Medication	Amount Per day

PAST MEDICATIONS: List all medications and supplements which you have taken in the last 6 months

	Medication	Amount Per day

C. FAMILY HISTORY:

	Age	State of Health (if deceased, cause of death)
Father
Mother

	Brother(s)	Sister(s)	Age	State of health (if deceased, cause of death)

	Male Children	Female Children	Age	State of health (if deceased, cause of death)

Have any relatives had the following:*

	Yes	No	If yes, what relation?
Diabetes
High Blood Pressure
Heart Disease
Kidney Disease
Strokes
Hardening of the arteries
Arthritis or Rheumatism
Goiter
Cancer
Seizures

D. GENERAL REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes	No
Weakness
Tiredness: Early morning
Tiredness: Late afternoon
Weight change
Chills
Fever
Night sweats
Difficulty sleeping

D. EYES, EARS, NOSE, THROAT REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes	No
Decreased ability to see
Blurred vision
Pain in the eyes
Difficulty in hearing
Sinus trouble
Hoarseness
Pain in the neck

D. RESPIRATORY REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes	No
Cough
Shortness of breath
Pain in the chest

D. CARDIOVASCULAR REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes	No
Chest pain, tightness or squeezing
Shortness of breath when lying down
Need to sit up to breathe
Heart racing
Irregular heartbeat (palpitations)
Heart murmur
Swelling of the legs
Varicose veins
Leg pain at rest
Leg pain with exertion
Blue or purple discoloration of hands/feet

D. BREASTS REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes	No
Lumps
Pain
Discharge

D. GASTROINTESTINAL REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes	No
Nausea
Vomiting
Diarrhea
Constipation
Heartburn
Abdominal pain
Bright red blood in stools
Black stools
Change in bowel habits
Food intolerance
Need for antacids
Hemorrhoids

D. URINARY REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes	No
Urinary tract infections
Pain or burning on urination
Frequent urination

D. GENITO-REPRODUCTIVE (Male) REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes	No
Discharge from penis
Testicular pain
Lumps in testicles or scrotum
Decrease in testicular size
Decreased sexual desire
Decreased ability to achieve erection

D. GENITO-REPRODUCTIVE (Female) REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes (only check if yes/no question)	No (only check if yes/no question)	Answer (if not yes/no question)
Age of onset of menstrual periods
Age which periods stopped (menopause)
How far apart are your periods?
How many days do they last?
Is flow heavy, scanty or normal?
Do you ever bleed between periods (Y/N)?
Does intercourse cause you undue pain (Y/N?
Do you have decreased sexual desire (Y/N)?
Any vaginal bleeding since menopause (Y/N)?
Are you bothered by hot flashes (Y/N)?
Are you taking any female hormones (Y/N?

D. OBSTETRICAL REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes (only check if yes/no question)	No (only check if yes/no question)	Answer (if not yes/no question)
Pregnancies: Full term deliveries (#)
Pregnancies: Miscarriages (#)
Pregnancies: Stillbirths (#)
Complications: High blood pressure (Y/N)
Complications: Toxemia (Y/N)
Complications: Severe hemorrhage (Y/N)
Complications: Diabetes (Y/N)
Complications: Any children over 9 lbs (Y/N)
Complications: Other please indicate

D. MUSCULOSKELETAL REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes	No
Painful joints
Swelling of any joints
Redness of any joints
Stiffness of any joints
Deformities of joints/extremities
Muscle pain
Back pain
Pain down the back of your legs

D. ENDOCRINE REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes	No
Goiter
Heat intolerance
Cold intolerance
Tremulousness of the hands
Change in pitch of voice
Increased body hair (face, underarms, pubic)
Decreased body hair (face, underarms, pubic)
Loss of periods (disregard if normal menopause)
Increased thirst
Marked increase in appetite

D. SKIN REVIEW OF SYSTEMS: Please check yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank.

	Yes	No
Dryness of skin
Change in skin color
Falling out of the hair
Skin ulcers