Health History Questionnaire

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Health History Questionnaire

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

Sex
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ALLERGIES
PERSONAL HEALTH HISTORY
Personal Health History
FAMILY MEDICAL HISTORY
Please indicate if any blood relatives (parents, grandparents, siblings) have had any of the following:
Family Medical History
SURGICAL HISTORY
Please list the type(s) of surgeries, hospitalizations, or serious injuries you have had.
Surgical History
IMMUNIZATIONS
Immunizations
List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Name of Drug
Strength
Frequency Taken
 
Up to 5 drugs
SOCIAL HISTORY
All questions contained in this questionnaire are optional and will be kept strictly confidential.
Caffeine
Alcohol
Do You Drink Alcohol?
If yes, what kind?
Tobacco
Do you smoke or use tobacco products?
Drugs
Do you currently use recreational or street drugs?
Have you ever given yourself street drugs with a needle?
Marital Status
Intensity

I certify to the best of my knowledge this information is complete and accurate.

MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.