Health History Questionnaire

Health History Questionnaire
Name *

First Name Middle Initial Last Name
Email *
example@example.com
Date of Birth *

Month Day Year
Date
Gender *

Male Female
Phone Number *
Please enter a valid phone number.
Martial Status *

Single Married Partnered Separated Divorced Widowed
Pharmacy *
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *
Please enter a valid phone number.

Health Habits

List your prescribed drugs and Over-the-Counter drugs, such as vitamins and inhalers *

	Name of Drug	Strength	Frequency Taken
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Allergies to Medications *

	Name of drug	Reaction you had	Severity
1
2
3
4
5
6

Allergies to Foods *

	Name the food or ingredient (milk, whey, cocoa, etc.)	Reaction you had	Severity
1
2
3
4
5
6

Family Health History

Please enter your family health history on the table below: *

	Alive or Deceased	Male or Female	Age	Significant Health Problems (required for Father and Mother)
Father
Mother
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Child 1
Child 2
Child 3
Child 4
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Aunt
Uncle

Sleep Apnea Questionnaire

*

	Yes	No
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
Do you often feel TIRED, fatigued, or sleepy during daytime?
Has anyone OBSERVED you stop breathing during your sleep?
Do you have or are you being treated for high blood PRESSURE?