HEALTH HISTORY QUESTIONNAIRE
Patient's Name
First Name
Middle Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Reason for visit
PLEASE LIST
Current Medications
Drug Allergies & Reactions
1
2
3
4
5
GYNECOLOGICAL HISTORY
Age you began menstruating:
First day of last period:
Menstrual flow:
Regular
Irregular
Painful/Cramps
Length of cycle:
Days of flow:
Menopausal?
Yes
No
If yes, what age did you begin menopause?
PREGNANCY:
Year
# of weeks at delivery
Hours of labor
Weight
Sex
Delivery type (Vaginal or C-section)
Location of delivery
Complications
1
2
3
4
Current birth control method:
Name of pill:
(if on pills)
Date of last pap smear:
-
Month
-
Day
Year
Date
Normal
Abnormal
Have you had an abnormal pap smear before?
Yes
No
Have you ever had a sexually transmitted disease?
Yes
No
If yes, please list date and type:
Date of last mammogram:
-
Month
-
Day
Year
Date
Result:
Normal
Abnormal
Date of last colonoscopy:
-
Month
-
Day
Year
Date
Result:
Normal
Abnormal
Are you a smoker?
Yes
No
If yes, how many packs daily?
If quit, how long ago?
Do you drink alcohol?
Yes
No
If yes, how many drinks per week?
Do you use drugs?
Yes
No
If yes, what type?
What is your exercise routine?
Frequency & type:
HAVE YOU HAD ANY OF THE FOLLOWING CONDITIONS?
Yes
No
Lung Disease
Bronchitis
Emphysema
Asthma
Sinusitis
Cold or Respiratory Infections
Pneumonia
Shortness of Breath
Lung Disease
Cancer
Cardiovascular
High Blood Pressure
Heart Attack
Heart Murmur
Circulation Disorder
Heart Disease
Clotting/Bleeding Disorder
Chest Pain
Stroke
Anemia
Systemic
Diabetes
Thyroid
Arthritis
Kidney/Bladder
Stomach/Bowel
Hepatitis
Seizure Disorder
Muscle Weakness
Glaucoma
LIST ALL PRIOR SURGERIES:
FAMILY HISTORY
Condition
Mother
Father
Sibling
Other
Breast Cancer
Ovarian Cancer
Uterine Cancer
Other Cancer
Osteoporosis
Heart Disease
Alcoholism
Kidney Disease
Thyroid Disease
Mental Illness
Diabetes
High Blood Pressure
PLEASE LIST ANY OTHER SIGNIFICANT MEDICAL ISSUES NOT LISTED ABOVE:
Submit
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