Adult Wellness Questionnaire
Patient Name:
Date of Birth:
-
Month
-
Day
Year
Date
Today's Date:
-
Month
-
Day
Year
Date
CONSTITUTIONAL
In the past year have you....?
Do you have excess fatigue?
Yes
No
Has your weight changed in the last year?
Yes
No
If Yes, Loss or Gain?
Loss
Gain
How many pounds?
Have you had fevers, chills or night sweats?
Yes
No
Do you consume alcohol?
Yes
No
Sometimes
Do you consume drugs?
Yes
No
Sometimes
Do you consume caffeine?
Yes
No
Sometimes
SKIN
In the past year have you....?
Have you had problems with dry skin, rash, eczema or itching?
Yes
No
Have you had skin lesions that have changed in size, shape or color?
Yes
No
Are you concerned about any skin lesions that you think could be cancerous?
Yes
No
EYES
In the past year have you....?
Have you had problems with loss of vision, double vision or blurred vision?
Yes
No
Do you wear glasses or contacts?
Yes
No
HEAD AND NECK
In the past year have you....?
Have you had problems hearing?
Yes
No
Have you had ringing in your ears?
Yes
No
Have you had problems with sense of smell or nose bleeds?
Yes
No
Have you had sinus infections or congestion?
Yes
No
Have you had problems with teeth, gum or throat?
Yes
No
Have you had problems with swallowing or neck pain?
Yes
No
Have you had frequent hoarseness, or change in character of your voice?
Yes
No
CARDIOVASCULAR
In the past year have you....?
Do you notice chest pain, ache, pressure, discomfort or tightness?
Yes
No
If so, how long does it last?
Is it caused by exertion?
Do you notice irregular or rapid heart beating?
Yes
No
Have you noticed swelling in your feet, ankles or hands?
Yes
No
Has your exercise tolerance changed?
Yes
No
RESPIRATORY
In the past year have you....?
Have you had a cough, wheezing or shortness of breath?
Yes
No
Have you coughed up any blood?
Yes
No
Do you use tobacco products?
Yes
No
If yes, what kind?
GASTROINTESTINAL
In the past year have you...?
Do you have trouble swallowing?
Yes
No
Are you bothered by heartburn?
Yes
No
Have you had black tarry stools?
Yes
No
Have you had a change in bowel movements?
Yes
No
Have you passed blood with one or more bowel movements?
Yes
No
Do you have problems with either diarrhea or constipation?
Yes
No
NEUROLOGICAL
In the past year have you....?
Have you had frequent or periodic headaches?
Yes
No
Have you had dizziness or passing out?
Yes
No
Have you had problems with memory?
Yes
No
Do you have a tremor or shaking of hands?
Yes
No
Have you had numbness, tingling or weakness of the extremities?
Yes
No
PSYCHIATRIC
In the past year have you....?
Do you feel depressed?
Yes
No
Do you feel stressed?
Yes
No
Do you cry frequently?
Yes
No
Do you have problems with appetite?
Yes
No
Is anxiety a problem for you?
Yes
No
Do you have trouble sleeping?
Yes
No
Are you dissatisfied with our life?
Yes
No
Do you desire counseling?
Yes
No
ENDOCRINE
In the past year have you....?
Do you have excessive thirst or urination?
Yes
No
Do you have heat or cold intolerance
Yes
No
Unexplained hair loss?
Yes
No
HEMATOLOGICAL
In the past year have you....?
Do you bruise easily or have trouble with bleeding>
Yes
No
Have you noticed any enlarged lymph nodes?
Yes
No
ALLERGIC/IMMUNOLOGIC
In the past year have you....?
Do you have seasonal allergy symptoms, congestion, itchy eyes or sneezing?
Yes
No
Have you had wheezing at rest or with activity?
Yes
No
MUSCULOSKELETAL
In the past year have you....?
Have you had joint pain, stiffness, redness or swelling?
Yes
No
Have muscle pain, weakness or cramps?
Yes
No
Have you had neck or back pain?
Yes
No
Have you had pain in the legs while walking?
Yes
No
MEN - GENITOURINARY
In the past year have you....?
Do you have to urinate at night?
Yes
No
How many times?
Do you have problems emptying the bladder completely?
Yes
No
In the past year have you had a kidney, bladder or prostate infection?
Yes
No
Have you had blood in the urine or semen?
Yes
No
Do you have abnormal sexual drive, difficulty with erections?
Yes
No
WOMEN - GENITOURINARY
In the past year have you....?
Do you have problems with control of urination?
Yes
No
Do you have to urinate at night?
Yes
No
How often?
In the past year, have you had a kidney or bladder infection?
Yes
No
Have you had blood in the urine?
Yes
No
Have you had an unusual discharge from the vagina?
Yes
No
Do you have discomfort with intercourse or decrease in sexual drive?
Yes
No
Have you had hot flashes, sweating at night or vaginal dryness?
Yes
No
Date of last menstrual period?
-
Month
-
Day
Year
Date
Have you had vaginal spotting/bleeding at times other than a menstrual period?
Yes
No
Have your menstrual periods changed in frequency, regularity or amount?
Yes
No
Do you have menstrual tension or other symptoms at the time of your period?
Yes
No
Have you had recent breast tenderness, lumps or nipple discharge?
Yes
No
Do you do a self-breast exam?
Yes
No
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