rblaseraesthetics.com - Health History Questionnaire

Health History Questionnaire

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE STRICTLY CONFIDENTIAL AND WILL BECOME PART OF YOUR MEDICAL RECORD.
Name:

First NameLast Name
Gender:

MaleFemale
D.O.B :

MonthDayYear
Date
Marital Status:

SinglePartneredMarriedWidowedSeparatedDivorced
Previous Referring Dr:
Date of Last Exam:

MonthDayYear
Date
Personal History
Childhood Illness:

MeaslesMumpsRubellaChickenpoxPolioRheumatic Fever

Immunizations and Dates:

	Check	Date
Tetanus
Pneumonia
Hepatitis
Chickenpox
Influenza
Measles
Mumps
Rubella

List Any Medical Problems That Other Doctors Have Diagnosed:
Surgeries:
Other Hospitalizations
Have you ever had a blood transfusion?

YesNo
Date of Transfusion:

MonthDayYear
Date
Location:
Woman Only:
Age at onset menstruation:
Date of last menstruation:

MonthDayYear
Date
Period every____days:
Write days
Heavy Periods, Irregular, Spotting, Pain, Discharge?

YesNo
Number or Pregnancies
Number or Live births
Are you pregnant or breast feeding?

YesNo
Have you had a D&C, Hysterectomy, or Cesarean?

YesNo
Any urinary tract, bladder, or kidney infections within the last year?

YesNo
Any blood in your urine?

YesNo
Any hot flashes or sweating at night?

YesNo
Do you have menstrual tension, pain, bloating, irritability or other symptoms at or around the period?

YesNo
Experienced any recent breast tenderness, lumps, or nipple discharge?

YesNo
Date of last pap and rectal exam?

MonthDayYear
Date
Any problem with control of urination?

YesNo
Men Only
Do you usually get up to urinate during the night?

YesNo
If yes, how many times?
Do you feel pain or burning with urination?

YesNo
Do you feel pain or burning with urination?

YesNo
Any blood in your urine?

YesNo
Do you feel burning discharge from penis?

YesNo
Has the force of your urination decreased?

YesNo
Have you had any kidney, bladder, or prostate infections within the last 12 months?

YesNo
Do you have any problems emptying your bladder completely?

YesNo
Any difficulty with erections or ejaculation?

YesNo
Any testicle pain or swelling?

YesNo
Date of last prostate and rectal exam

MonthDayYear
Date
Other Problems
Check if you have, or have had any symptoms in the following areas to a significant degree and briefly explain

SkinHead/NeckEarsNoseThroatLungsChest/HeartBackIntestinalBladderBowlCirculation
Recent Changes in:

WeightEnergy LevelAbility to sleepOther Pain/Dicomfort
Sexual History
Are you sexually active?

YesNo
If yes, are you trying for a pregnancy?

YesNo
If not trying for a pregnancy, list contraceptive or barrier method used:
Any discomfort with intercourse?

YesNo
Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?

YesNo
Do you live alone?

YesNo
Do you have frequent falls?

YesNo
Do you have vision or hearing loss?

YesNo
Do you have an Advance Directive or Living Will?

YesNo
Would you like information on the preparation of these?

YesNo
Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?

YesNo
Family History

	Age	Significant Heart Problems
Father
Mother
Grandmother (Maternal)
Grandfather (Maternal)
Grandmother (Paternal)
Grandfather (Paternal)

	Age	Gender	Significant Heart Problems
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Sibling 5
Children 1
Children 2
Children 3
Children 4

Mental Health
Is stress a major problem for you?

YesNo
Do you feel depressed?

YesNo
Do you panic when stressed?

YesNo
Do you have problems with eating or your appetite?

YesNo
Do you cry frequently?

YesNo
Have you ever attempted suicide?

YesNo
Have you ever seriously thought about hurting yourself?

YesNo
Do you have trouble sleeping?

YesNo
Have you ever been to a counselor?

YesNo
List your prescribed and over-the-counter drugs , such as vitamins and inhalers
Allergies
Health and Perosnal Safety
Exercise
Exercise

Sedentary (no exercise)Mild Exercise (I.e, climb stairs, walk 3 blocks, golf)Occasional Vigorous Exercise (I.e, work or recreation, less than 4x/week for 3Omins)Regular Vigorous exercise (I.e, work or recreation 4x/week for 3Omins
Diet
Are you dieting?

YesNo
If yes, are you on a physician prescribed medical diet?

YesNo
# of meals you eat in an average day?
Rank Salt intake

HighMedLow
Rank Fat intake

HighMedLow
Caffeine
Caffeine

NoneCoffeeTeaCola
# of cups/cans per day?
Alcohol
Do you drink alcohol?

YesNo
If yes, what kind?
How many drinks per week?
Are you concerned about the amount you drink?

YesNo
Have you considered stopping?

YesNo
Have you ever experienced blackouts?

YesNo
Are you prone to "binge" drinking?

YesNo
Do you drive after drinking?

YesNo
Do you use tobacco?

YesNo
CigarettesChewPipeCigars
Cigarettes - Pks/day
Chew- #/day
Pipe- #/day
Cigars- #/day
Drugs
Do you currently use recreational or street drugs?

YesNo
Have you ever given yourself street drugs with a needle ?

YesNo
Should be Empty:

Health History Questionnaire

Personal History