Health Questionnaire

Patient: Age: Date:

Do you have or have you ever had any of the following conditions:

[_] 1 Alcoholism

[_] 2 Allergies

[_] 3 Alzheimer’s Disease

[_] 4 Anemia

[_] 5 Anxiety

[_] 6 Arm and Hand Problems

[_] 7 Arthritis

[_] 8 Bed Wetting

[_] 9 Blood in Urine

[_] 10 Breast Soreness

[_] 11 Cancer or tumor

[_] 12 Change in Bowel Habits

[_] 13 Chest Pain

[_] 14 Chronic Cough

[_] 15 Cold Feet

[_] 16 Cold Hands

[_] 17 Colds

[_] 18 Colitis

[_] 19 Confusion

[_] 20 Constipation

[_] 21 Convulsions

[_] 22 Coughing up Phlegm

[_] 23 Crying

[_] 24 Dental Problems

[_] 25 Depression

[_] 26 Diabetes

[_] 27 Diarrhea

[_] 28 Difficult Breathing

[_] 29 Difficult Urination

[_] 30 Dizziness

[_] 31 Ear Discharge

[_] 32 Endometriosis

[_] 33 Epilepsy

[_] 34 Excessive Belching

[_] 35 Excessive Gas

[_] 36 Excessive Hunger

[_] 37 Excessive Urination

[_] 38 Eyestrain

[_] 39 Fainting

[_] 40 Fear

[_] 41 Fever

[_] 42 Foot Problems

[_] 43 Frequent Urination

[_] 44 Gall Bladder Problems

[_] 45 Headaches

[_] 46 Hearing Impairment

[_] 47 Heart Attack

[_] 48 Heart Disease

[_] 49 Heart Problems

[_] 50 Heartburn after Meals

[_] 51 Hemorrhoids

[_] 52 Hepatitis

[_] 53 Hernia

[_] 54 High Blood Pressure

[_] 55 Hoarseness

[_] 56 Hospitalizations

[_] 57 Infections

[_] 58 Irregular Flow

[_] 59 Kidney Problems

[_] 60 Kidney Disease

[_] 61 Leg Problems

[_] 62 Liver Problems

[_] 63 Loss of Bladder Control

[_] 64 Low Back Pain

[_] 65 Low Blood Pressure

[_] 66 Lumps in Breasts

[_] 67 Measles

[_] 68 Menopause Problems

[_] 69 Miscarriage or Abortions

[_] 70 Multiple Sclerosis

[_] 71 Mumps

[_] 72 Muscular Dystrophy

[_] 73 Nausea

[_] 74 Neck Pain

[_] 75 Nervousness

[_] 76 Nosebleeds

[_] 77 Pain Between the Shoulders

[_] 78 Pain in Testicles

[_] 79 Pain over Stomach

[_] 80 Pain over the Heart

[_] 81 Painful Joints

[_] 82 Painful Menstruation

[_] 83 Painful Urination

[_] 84 Paralysis

[_] 85 Parkinson’s Disease

[_] 86 PMS

[_] 87 Pneumonia

[_] 88 Polio

[_] 89 Poor Appetite

[_] 90 Profuse Flow

[_] 91 Rapid Heartbeat

[_] 92 Rheumatic Fever

[_] 93 Sexual Difficulties

[_] 94 Sinusitis

[_] 95 Skin Problems

[_] 96 Sore Throat

[_] 97 Stroke

[_] 98 Sweats

[_] 99 Swollen Joints

[_] 100 Syphilis

[_] 101 Thyroid condition

[_] 102 Tonsillitis

[_] 103 Tremors

[_] 104 Tuberculosis

[_] 105 Ulcers

[_] 106 Vaginal Discharge

[_] 107 Varicose Veins

[_] 108 Vision Impairment

[_] 109 Weigh Gain or Loss

v Do you use:

o Alcohol

o Tobacco

o Birth Control Pills

o Caffeine

o Soft Drinks

o Recreational Drugs

v Do you:

o Exercise

Or do other types of:

o Recreational Activities

v Is you complaint interfering with your:

o Work

o Sleep

o Daily Routine

v Do you wear:

o Heel lifts

o Sole lifts

o Inner Soles

o Arch Supports

v Number of Successful Pregnancies:

v Average Number of Hours of Sleep per Night:

v FAMILY HISTORY

[_] 110 Arthritis

[_] 111 Cancer

[_] 112 Diabetes

[_] 113 Heart Disease

[_] 114 Kidney Disease

[_] 115 Tuberculosis

[_] 116 Other

Continue of reverse side

Patient: Age: Date:

List all medications you are currently taking and how much:

List all the vitamins and supplements you are currently taking and how much:

List all the different doctors and their specialties you have seen in the last 3 years:

Date Doctor Treatment and Results

List all hospitalizations and/or surgeries you have had in the last 5 years:

Date Doctor Surgery Results

For what condition(s) or problem(s) are you wanting to be seen?

Is there anything else you feel the doctor should know about your health?

Date of last full exam

Date of last pelvic exam

Date of last prostate exam