Personal Health History

Patient Name Date

Reason for your visit

PAST HISTORY

Have you ever had any of the following illnesses?

Angina pectoris	Yes No	Asthma	Yes No
Heart attack	Yes No	Emphysema	Yes No
Other heart disease	Yes No	Diabetes	Yes No
High blood pressure	Yes No	Cancer	Yes No
Anemia	Yes No	Thyroid disease	Yes No
Kidney disease	Yes No	Stomach ulcers	Yes No
Gout	Yes No	Hepatitis	Yes No

Are you allergic to any medications? Yes No
If yes, please list medications and the reaction you had to them:

MEDICATIONS (include dosage and times per day)

SURGERIES (include Surgery and Approximate Date)

PERSONAL HABITS
Did you ever smoke?   Yes No
Cigarettes   Packs per day
Pipe Cigars
How long have you been smoking (years)?    When did you quit (year)?

Do you drink alcohol? Yes No    Quantity

FAMILY HISTORY

	If Alive		If Deceased
	Age	Health	Age at Death	Cause
Father
Mother
Brother/Sister (Choose sex) M F
M F
M F
M F
M F

LAST: Tetanus Pneumovax Flu Shot Colonoscopy
Female: Pap Bone Density Mammogram

REVIEW OF SYMPTOMS

GENERAL		GASTROINTSTINAL
Do you usually feel tired or worn out?	Yes No	Any change in your eating habits?	Yes No
Do you feel depressed a lot of the time?	Yes No	Are there any foods that cause you to have stomach pains, nausea, etc?	Yes No
Have you been drinking more fluids?	Yes No	Any trouble swallowing?	Yes No
Have you noticed that warm weather bothers you?	Yes No	Do you have indigestion or heartburn?	Yes No
Has there been any unusual weight gain or loss?	Yes No	Have you ever vomited blood?	Yes No
		Are you bothered with constipation?	Yes No
SKIN		Do you have frequent diarrhea?	Yes No
Have you noticed		Have you ever passed blood from your rectum?	Yes No
change in the color of your skin?	Yes No	Have you ever had black or tarry stools?	Yes No
skin rashes or itching?	Yes No	Any recent change in your bowel movements?	Yes No
unusually dry skin?	Yes No
growth on your skin that bothers you?	Yes No	GENITOURINARY
sores or wounds that do not heal?	Yes No	Do you have:
change in color or size of warts?	Yes No	burning or pain when you urinate?	Yes No
		to get up to urinate at night?	Yes No
ENT		trouble losing urine when you cough or sneeze?	Yes No
Do you have:		dribbling urine?	Yes No
any trouble hearing?	Yes No	Have you ever passed blood in your urine?	Yes No
ringing or buzzing in your ears	Yes No	Men, do you have prostate gland trouble?	Yes No
frequent or severe nosebleeds?	Yes No
persistent hoarseness?	Yes No	MUSCULOSKELETAL
a lump in your throat	Yes No	Do you have a problem with back pain?	Yes No
a sore mouth or tongue?	Yes No	Do you have joint pain or stiffness?	Yes No
bleeding gums?	Yes No	Do you have trouble walking or using your hip or knee joints?	Yes No

RESPIRATORY		CENTRAL NERVOUS SYSTEM
Do you have:		Do you have frequent or severe headaches?	Yes No
a constant or bothersome cough?	Yes No	Do you often have spells of dizziness or faintness?	Yes No
coughing up blood?	Yes No	Have you ever seen double?	Yes No
difficulty breathing?	Yes No	Have you recently fainted, blacked out, or lost consciousness?	Yes No
Have you noticed any wheezing?	Yes No	Do you have numbness or tingling in your head, arms, or legs?	Yes No
		Do you have trouble remembering recent events?	Yes No
CARDIOVASCULAR		Do you consider yourself a nervous person?	Yes No
Do you have pain, tightness or pressure in your chest?	Yes No	Do you cry a lot for no reason?	Yes No
Do you have swelling of your feet?	Yes No
Does your heart ever beat fast or irregularly?	Yes No	WOMEN ONLY
Do you have cramps in the calf muscles when you walk?	Yes No	Are your menstrual periods regular?	Yes No
Do you ever awaken at night with severe difficulty breathing?	Yes No	Do you pass clots with your periods?	Yes No
		Have you passed the menopause or change?	Yes No
		Do you have hot flashes?	Yes No
		Have you had any lumps in your breasts?	Yes No