Health History

Health History Questionnaire

Joan Takacs, D.O. & John Takacs, D.O.
MonthDayYear
Today's Date
Patient Name*

First NameMiddle NameLast Name
MonthDayYear
Date of Birth
Age
Preferred Name (if any):
OccupationEmployer
for how long
Emergency contact:

NameRelationship
Phone Number
Please enter a valid phone number.
If Child - Do you live with both parents?

YesNo
If No, explain:
Gender

MaleFemaleOther
Marital Status

MarriedDivorcedSingleWidowedPartnered
Education History

Highest Grade Level Completed (1-12): Number   GED
College (1-4 years):   Number
Post Grad      Number   # years   describe degree

List All Persons Who Live in Your Household:

Have You or a Blood Relative Had: (Check if Yes)

	You	Blood Relative
Diabetes
Cancer
High Blood Pressure
Heart Trouble
Elevated Cholesterol and/or Triglycerides
Asthma
Hay Fever
Lung Problems
Thyroid Problems
Kidney, Bladder or Urinary Problem
Stroke
Stomach or Bowel Problems
Liver Problem or Hepatitis
Birth Defects
Arthritis
Anxiety or Depression
Psychiatric
Fatigue
Sleep Apnea
Migraines
Fibromyalgia

Allergies: (Medicines or others)

None
Describe (4 lines limit):
List All Medications Taken on a Regular Basis, including Herbal, Vitamins, Injections, Over-the-Counter, Prescriptions, etc. :

None

Have you traveled out of the country this year?

Date Where did you travel place name
Preferred Pharmacy/Location/Phone#

Surgical History:

Please list ALL physicians/providers you are currently treating with:

Health History Questionnaire