HEALTH HISTORY QUESTIONNAIRE
Name (First Last)
*
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Email Address
Do you have any allergies (include food, medication, and environmental)
*
Current Diagnoses (Please indicate if you suspect you have something but have not been officially evaluated and diagnosed by a physician)
*
Medications (Include Supplements)
*
Family Medical History
Family History of Diagnosed Medical Problems (Please include Maternal/Paternal indicators)
Social History
What is the highest grade or level of school you have completed
*
Please Select
Elementary (1-6th) Grade
Middle School (7th or 8th) Grade
High School (9-12th) Grade
High School Graduate (Diploma)
GED or equivalent
Some College, No degree
Associates Degree
Bachelor's Degree
Masters Degree
Professional School Degree (MD)
Doctoral Degree
Are you currently Employed
*
Yes
No
Are you able to care for yourself?
*
Yes
No
Are you blind or do you have difficulty seeing?
*
Yes
No
Are you deaf or do you have serious difficulty hearing?
*
Yes
No
Do you have difficulty concentrating, remembering or making decisions?
*
Yes
No
Do you have difficulty walking or climbing stairs?
*
Yes
No
Do you have difficulty dressing or bathing?
*
Yes
No
Do you have difficulty doing errands alone?
*
Yes
No
Do you need assistive devices to walk?
*
Yes
No
Do you have transportation difficulties?
Yes
No
Do you or have you ever smoked tobacco?
*
Please Select
Never Smoker
Former Smoker
Current Everyday Smoker
Current Some Days Smoker
Do you or have you ever used any other forms of tobacco or nicotine?
*
Yes
No
What is your level of alcohol consumption?
*
Please Select
None
Occasional
Moderate
Heavy
Do you use any illicit or recreational drugs?
*
Yes
No
What is your level of caffeine consumption?
*
None
Occasional ( 1/day or less)
Moderate (1-2/day)
Heavy (>2 /day)
Do you have an advanced directive?
*
Yes
No
Is blood transfusion acceptable in an emergency?
*
Yes
No
Have there been any recent changes to your family or social situation?
Do you have any pets?
Yes
No
Do you have smoke and carbon monoxide detectors in your home?
Yes
No
Are you passively exposed to smoke?
Yes
No
Are there any guns present in your home?
Yes
No
What is the fluoride status of your home?
Fluoridated (City Water)
Unfluoridated (Well Water)
Unknown
Do you use insect repellent routinely?
Yes
No
Do you use sunscreen routinely?
Yes
No
Do you feel stressed (tense, restless, nervous, or anxious, or unable to sleep at night)?
*
Please Select
Not at all
Only a little
To some extent
Rather much
Very Much
Do you participate in social media?
*
Yes
No
Do you wear a helmet when biking?
*
Yes
No
Do you use your seat belt or car seat routinely?
*
Yes
No
What is your relationship status?
*
Unknown
Married
Single
Divorced
Separated
Widowed
Domestic Partner
Other
Are you sexually active?
*
Yes
No
How many children do you have?
What type of diet are you following?
*
Please Select
Regular
Vegetarian
Vegan
Gluten Free
Specific
Carbohydrate
Cardiac
Diabetic
What is your exercise level?
*
None
Occasional( 1/week or less)
Moderate (1-3/week)
Heavy( 4/week or more)
How many days of moderate to strenuous exercise, like a brisk walk, did you do in the last 7 days?
*
What types of sporting activities do you participate in?
Surgical History
Please List Any Surgeries below (Specify dates, if possible)
Do you have a Vagina?
*
Yes
No
OB/Gyn History
Date of last Pap smear
-
Month
-
Day
Year
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If post menopausal, age at menopause
Do you have your HPV vaccine
Yes
No
Unknown
Are you sexually active?
Yes
No
Have you ever had an STI?
Yes
No
Are you on Birth Control, If so which kind?
No
Other
Date of end of last period cycle
-
Month
-
Day
Year
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Duration of last period
Frequency of Cycle in Days (Every 28 days is "Average")
Have you ever been pregnant?
*
Yes
No
Yes, but the pregnancy did not reach full term
Other
Common Medical Conditions Screening
Please click yes if you have, suspect you have, or have ever had the condition. Please click no if you do not, have not, or do not know what the condition is
ADD/ADHD
*
Yes
No
AIDS/HIV
*
Yes
No
Abuse/Domestic Violence
*
Yes
No
Allergies/Hayfever
*
Yes
No
Amnesia
*
Yes
No
Anemia
*
Yes
No
Anesthesia Complications
*
Yes
No
Anxiety Disorder
*
Yes
No
Arthritis
*
Yes
No
Asthma
*
Yes
No
Auditory Hallucinations
*
Yes
No
Autism Spectrum Disorder (ASD)
*
Yes
No
Incontinence
*
Yes
No
Birth Defects or Inherited Disease
*
Yes
No
Bladder or Kidney Problems
*
Yes
No
Blood Diseases
*
Yes
No
Blood Transfusion
*
Yes
No
Brain Injury (including concussions)
*
Yes
No
Mammary Gland or Tissue Problems
*
Yes
No
COPD
*
Yes
No
Cancer
*
Yes
No
Chicken Pox
*
Yes
No
Chronic Ear Infections
*
Yes
No
Congestive Heart Failure (CHF)
*
Yes
No
Constipation
*
Yes
No
Coronary Artery Disease
*
Yes
No
Depression
*
Yes
No
Developmental or Behavioral Disorders
*
Yes
No
Diabetes
*
Yes
No
Difficulty Swallowing
*
Yes
No
Diverticulitis
*
Yes
No
Eating Disorder
*
Yes
No
Eczema
*
Yes
No
Endometriosis
*
Yes
No
Fibromyalgia
*
Yes
No
GERD/Reflux
*
Yes
No
GI Problems
*
Yes
No
Gout
*
Yes
No
Headaches
*
Yes
No
Heart Disease
*
Yes
No
Heart Problems
*
Yes
No
Hepatitis
*
Yes
No
High Cholesterol
*
Yes
No
Hospitalizations
*
Yes
No
Hypertension
*
Yes
No
Hyperthyroidism
*
Yes
No
Hypothyroidism
*
Yes
No
Infertility
*
Yes
No
Kidney Disease
*
Yes
No
Kidney Stones
*
Yes
No
Learning Disorder
*
Yes
No
Liver Disease
*
Yes
No
Lung Disease
*
Yes
No
MRSA exposure
*
Yes
No
Meniere's disease
*
Yes
No
Muscle, Joint, or Bone Problems
*
Yes
No
Obesity
*
Yes
No
Osteoporosis
*
Yes
No
Polyps
*
Yes
No
Pre-Eclampsia
*
Yes
No
Psychiatric/Mental Health Condition
*
Yes
No
Pulmonary Embolism
*
Yes
No
Schizophrenia
*
Yes
No
Seizures/Epilepsy
*
Yes
No
Skin Problems
*
Yes
No
Stroke
*
Yes
No
Suicidal Ideation/Suicide attempt
Yes
No
Thrombophilias
*
Yes
No
Thyroid Disease
*
Yes
No
Thyroid Problems
*
Yes
No
Tourette Syndrome
*
Yes
No
Tuberculosis
*
Yes
No
Varicosities
*
Yes
No
Visual Hallucinations
*
Yes
No
Submit
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