PATIENT HEALTH CARE QUESTIONNAIRE

PATIENT HEALTH CARE QUESTIONNAIRE
Name*

First NameMiddle Name / MILast Name
Date of Birth*

MonthDayYear
Date
I am a*

New PatientEstablished Patient
What medical concerns do you wish to discuss:
1.
2.
3.
Marital Status
Professional Title
Please check if disabled

Check here
Nature of Disability
Do you exercise routinely?

YesNo
If Yes: Type of Exercise
How Often?
Have you ever smoke?*

YesNo
Patient Smoking Status

CigarettesE-CigarettesChewing TobaccoPipeCigar
Patient Smoking Frequency
# of Years
Have you attempted to Quit?

YesNo
Patient Smoking End Date

MonthDayYear
Date
Have you completed an Advanced Directive or a Living Will?*

YesNo
Which?
Caffeine: Do you drink (check)

CoffeeTeaSodasRed Bull
regularly?

YesNo
#/Day
Home Environment (e.g. live alone, with family, single parent, house, etc.)*
Are you under a lot of pressure at work or at home?

YesNo
Allergies: Drug*

YesNo
Please List
Allergies: Food*

YesNo
Please List
Medications (List/Attach All medications you are taking regularly. Include OTC, Supplements, Herbal, or natural remedies)*
Medical Illnesses or Chronic Conditions?
Please List*
Have you ever had or been diagnosed to have: (check all that apply)*

CataractsHeart DiseaseUlcersAnemiaGlaucomaHeart MurmurDigestive DisorderBleeding DisorderAsthmaHigh Blood PressureHemorrhoidsBone/Joint DiseaseAllergiesPneumoniaKidney DiseaseGerman MeaslesStrokeTB/Lung DiseaseKidney StonesRheumatic FeverSeizures/EpilepsyPleurisyDiabetes/PreDiabetesChicken Pox/ShinglesHeart Attack/AnginaJaundice/Liver DiseaseThyroid DiseaseSyphilisDepressionFreq. InfectionsCancerHigh CholesterolProstate EnlargementNone
Cancer (Type)
HOSPITALIZATIONS: Last 2-3 Years
Please list year, reason and a hospital
OPERATIONS : ALL
Please list year and type of a surgery
Family Medical History

Father
If deceased: Cause
Age at death
Age
List Significant Illness
Comment
Mother
If deceased: Cause
Age at death
Age
List Significant Illness
Comment
Brothers/Sisters
If deceased: Cause
Age at death
Age
List Significant Illness
Comment
Brothers/Sisters
If deceased: Cause
Age at death
Age
List Significant Illness
Comment
Brothers/Sisters
If Deceased: Cause
Age At Death
Age
List Significant Illness
Comment
Has any Blood Relative had? (check if Yes and indicate relationship)

TuberculosisBleeding DiseaseDiabetesStrokeAllergiesHigh Blood PressureSeizuresAsthmaHear DiseaseDepression/SuicideCancerOtherAlzheimer'sHeath Attack before age 55
IMMUNIZATIONS: Check if Yes and Indicate Year
Influenza*

YesNo
Year
Shingles/Zoster*

YesNo
Year
Tdap/Td Tetanus*

YesNo
Year
Pneumococcal*

YesNo
Year
MMR*

YesNo
Year
Meningococcal*

YesNo
Year
Hepatitis*

YesNo
Year
HPV*

YesNo
Year
Hepatitis A*

YesNo
Year
Hepatitis B*

YesNo
Year
Chicken Pox/Variacella*

YesNo
Year
Hib Influenzae Type b*

YesNo
Year
Transfusions: Have you ever had a blood or plasma transfusion (check)?*

YesNo
Year
Screenings: Check If Yes and Indicate Year
Mammogram*

YesNo
Year
Dexascan*

YesNo
Year
Colonoscopy*

YesNo
Year
PSA*

YesNo
Year
Constitutional Symptoms
Good Health Lately*

YesNo
Recent significant Weight Change*

YesNo
Unusual Fatigue or Weakness*

YesNo
Frequent Headaches*

YesNo
Eyes
Change In Vision*

YesNo
Blurred or Double Vision*

YesNo
Eye Disease or Injury*

YesNo
Wear Glasses/Contact Lenses*

YesNo
Ears/Nose/Mouth/Throat/Neck
Hearing Aids*

YesNo
Hearing Loss or Ringing in Ears*

YesNo
Earaches or Drainage*

YesNo
Chronic Sinus Problems*

YesNo
Nose Bleeds*

YesNo
Mouth sores*

YesNo
Bleeding Gums*

YesNoOther
Sore Throat/Hoarseness*

YesNo
Lumps/Swollen Glands in Neck*

YesNo
Difficulty Swallowing*

YesNo
Neck Pain or Stiffness*

YesNo
Cardiovascular
Heart Trouble*

YesNo
Chest Pain/Angina Pectoris*

YesNo
Palpitations*

YesNo
Shortness of Breath/Walking or Lying Flat*

YesNo
Swelling Feet/Ankles or Hands*

YesNo
Waking at Night w/Shortness of Breath*

YesNo
Respiratory
Chronic or Frequent Cough*

YesNo
Coughing or Spitting Up Blood*

YesNo
Shortness of Breath*

YesNo
Asthma or Recurrent Wheezing*

YesNo
Musculoskeletal
Joint Pain(s)*

YesNo
Joint Stiffness/Swelling or Warmth*

YesNo
Weakness of Muscles or Joints*

YesNo
Muscle Pain or Recurrent Cramps*

YesNo
Back Pain*

YesNo
Cold Hands or Feet*

YesNo
Difficulty In Walking*

YesNo
Gastrointestinal
Loss Of Appetite*

YesNo
Change In Bowel Movements*

YesNo
Nausea or Vomiting*

YesNo
Painful Bowel Movements or Constipation*

YesNo
Frequent Diarrhea*

YesNo
Rectal Bleeding or Blood in Stool*

YesNo
Stomach/Abdominal Pains or Heartburn*

YesNo
Black or Tarry Stools*

YesNo
Genitourinary
Frequent Urination*

YesNo
Burning or Pain on Urination*

YesNo
Blood in Urine*

YesNo
Change in Force or Strain when Urinating*

YesNo
Incontinence or Dribbling of Urine*

YesNo
Sexual Difficulties*

YesNo
Men Testicular Pain

YesNo
Women

Painful PeriodsIrregular PeriodsRecurrent Vaginal Discharge
Menopausal Years
Number of Pregnancies
Deliveries
Miscarriages
Integumentary (Skin/Breast)
Rashes or Itching*

YesNo
Change in Skin Color or Moles*

YesNo
Change in Hair or Nails*

YesNo
Varicose Veins*

YesNo
Breast Pain*

YesNo
Breast Lump*

YesNo
Breast Discharge or Rash*

YesNo
Neurological
Frequent, recurring or Increasing Headaches*

YesNo
Light-Headiness or Dizziness*

YesNo
Convulsions, Seizures or spasms*

YesNo
Numbness or Tingling Sensations*

YesNo
Tremors*

YesNo
Paralysis*

YesNo
Stroke*

YesNo
Head Injury*

YesNo
PLEASE NOTE: This section of the medical history contains questions that may be of a very personal nature and highly confidential aspect of your health. While we treat all information in your medical chart as confidential records, this section of the questionnaire is filed separately from the general medical data. It can be released only upon written consent from you for psychiatric, mental health and substance abuse records.

The following sets of questions are to help us identify problem areas that may be difficult to discuss. Select yes or no to each question and discuss any yes answers with your physician, nurse or mental health practitioners.
ALCOHOL and DRUGS
Do you drink alcohol? (select one)*

YesNo
If yes, check the following:

Beer Daily/WeeklyWine Daily/WeeklyHard Liquor - Daily/WeeklyRarely Social less than once
Beer Daily/Weekly
Wine Daily/Weekly
Hard Liquor Daily/Weekly
Do you use or have you used in the past marijuana, cocaine, heroin, speed, crack or inhalants?*

YesNo
Have you felt you need alcohol or Other drugs?*

YesNo
Have tried to cut down or quit drinking alcohol or your use of drugs?*

YesNo
Have you felt you use too much alcohol or other drugs?*

YesNo
Do you feel you have a drinking or a drug problem at this time?*

YesNo
PERSONAL SAFETY
Do you feel safe at home?*

YesNo
Have you been physically hurt or felt threatened by a family member?*

YesNo
Do you feel family members control or try to control your behavior too much?*

YesNo
Has any family member ever hit, pushed, shoved, punched or kicked you?*

YesNo
Have you ever felt forced to engage in unwanted sexual acts by a family member?*

YesNo
Please rate your support system:*

OptimalGoodAveragePoor
Mental Health
Have you been diagnosed to have depression?*

YesNo
Have you been diagnosed to have bi-polar, obsessive compulsive, or other psychiatric conditions?*

YesNo
Have you previously received mental health therapy?*

YesNo
Have you ever considered committing suicide?*

YesNo
Have you ever been diagnosed or treated for an eating disorder?*

YesNo
Have you experienced any special, unusual, or traumatic circumstance that affected your development?*

YesNo
SEXUALITY
Do you have any concerns or questions regarding your sexuality?*

YesNo
Have you or are you currently engaged in high risk sexual behavior?*

YesNo
HIV EXPOSURE
Have you ever been diagnosed to be HIV Positive?*

YesNo
Do you have any concerns about possible exposure that you would like to discuss or be tested for?*

YesNo
Should be Empty:

PATIENT HEALTH CARE QUESTIONNAIRE

Medical Illnesses or Chronic Conditions?

HOSPITALIZATIONS: Last 2-3 Years

OPERATIONS : ALL

Family Medical History

IMMUNIZATIONS: Check if Yes and Indicate Year

ALCOHOL and DRUGS

PERSONAL SAFETY

Mental Health

SEXUALITY

HIV EXPOSURE