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What is Lifestyle Medicine About Services Chip Program CPR, AED and First Aid Genetic Testing - Nutrigenomics & Pharmacogenomics The Lift Project 1-on-1 Program Diabetes Prevention Program Programs + Products Network Providers Employers Partners Resources Helpful Links FAQ Patient Forms Health History Questionnaire Agreement to Receive Electronic Communication Payment Policies General Patient Information Form New Patient Assessment Form 24 Hour Food Options Form Request to Participate (CHIP) Request to Participate (LIFT) Blog

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Health History Questionnaire

All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.

Name *

First Name

Last Name

Date of Birth *

YYYY

Marital Status *

Single

Partnered

Married

Separated

Divorced

Widowed

Previous or Referring Doctor *

First Name

Last Name

Date of last physical exam *

YYYY

Medical History: Childhood Illnesses *

Measles

Mumps

Rubella

Chickenpox

Rheumatic Fever

Polio

Immunizations + Dates: Tetanus *

YYYY

Immunizations + Dates: Hepatitus *

YYYY

Immunizations + Dates: Influenza *

YYYY

Immunizations + Dates: Pneumonia *

YYYY

Immunizations + Dates: Chickenpox *

YYYY

Immunizations + Dates: MMR *

Measles, Mumps, Rubella

YYYY

Please list surgeries and years they occured in *

Other hospitalizations? *

Have you ever had a blood transfusion? *

Yes

List your Prescribed and Over the Counter Medications: *INCLUDE DRUG NAME, DOSE + FREQUENCY TAKEN *

List Your Allergies to Medications + Reaction you had *

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 30 min.)

Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)

Are you dieting? *

Yes

If so, is it a Physician Prescribed Diet? *

Yes

Rank your average daily salt intake *

Low

Med

High

Rank your average daily fat intake *

Med

Low

High

Caffeine *

none

coffee

tea

cola

Do you drink Alcohol? *

Yes

If yes, what kind?

How many drinks per week?

Are you concerned about how much you drink?

Yes

Have you considered stopping?

Yes

Have you ever experienced blackouts?

Yes

Are you prone to Binge Drinking?

Yes

Do you Drive after Drinking?

Yes

Do you Use Tobacco? *

Yes

Do you use the follwoing?

Cigarettes

Cigars

Pipe Chew

List the number of years you've used each, how frequently you use each and or the year you quit

Do you currently use recreational drugs? *

Yes

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

Yes

Are you sexually active? *

Yes

If yes, Are you Trying for a Pregnancy? *

Yes

If not trying for a pregnancy list contraceptive or barrier method used: *

Any discomfort with intercourse? *

Yes

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? *

Yes

Do you live alone? *

Yes

Do you have frequent falls? *

Yes

Do you have vision or hearing loss? *

Yes

Do you have an advance directive or living will? *

Yes

Would you like information on the preparation of these? *

Yes

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? *

Yes

Family History: Father *

Describe health problems and age of this family member

Family History: Mother *

Describe health problems and age of this family member

Family History: Siblings

Describe health problems, gender and age of this family member

Family History: Children

Describe health problems, gender and age of this family member

Family History: Grandmother

Describe health problems and age of this family member

Family History: Grandfather

Describe health problems and age of this family member

Is stress a major problem for you? *

Yes

Do you feel depressed? *

Yes

Do you panic when stressed? *

Yes

Do you have problems with eating or your appetite? *

Yes

Do you cry frequently? *

Yes

Have you ever attempted suicide? *

Yes

Have you ever seriously thought about hurting yourself? *

Yes

Do you have trouble sleeping? *

Yes

Have you ever been to a counselor? *

Yes

Women only: Age at onset of menstruation:

Women Only: Date of last menstruation:

YYYY

Women Only: Period every _____ days

Women Only: Heavy periods, irregularity, spotting, pain, or discharge?

Yes

Women Only: Number of pregnancies _____ Number of live births _____

Women Only: Are you pregnant or breastfeeding?

Yes

Women Only: Have you had a D&C, hysterectomy, or Cesarean?

Yes

Women Only: Any urinary tract, bladder, or kidney infections within the last year?

Yes

Women Only: Any blood in your urine?

Yes

Women Only : Any problems with control of urination?

Yes

Women Only: Any hot flashes or sweating at night?

Yes

Women Only: Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?

Yes

Women Only: Experienced any recent breast tenderness, lumps, or nipple discharge?

Yes

Women Only: Date of last pap and rectal exam?

YYYY

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

Yes

If Yes, How many times?

Men Only: Do you feel pain or burning with urination?

Yes

Any Blood in your urine?

Yes

Do you feel burning discharge from penis?

Yes

Has the force of your urination decreased?

Yes

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

Yes

Do you have any problems emptying your bladder completely?

Yes

Any difficulty with erection or ejaculation?

Yes

Any testicle pain or swelling?

Yes

Date of last prostate and rectal exam?

YYYY

Health History Questionnaire

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.