MEDICAL HISTORY QUESTIONNAIRE

JAMES K. ROTCHFORD MD MPH

TODAY'S DATE: ___ / ___ / ___

NAME:_______________________________________________

DATE OF BIRTH: ___/___/___

IMPORTANT: This form is confidentiial. It will help us to better help to you in your health care, but you are not obliged to fill it out. If you prefer not to anwser a question(s), just leave the space blank. If you don't understand a question(s), ask the receptionist for help or bring it up with the doctor. Please complete any questions for which there is not enough room on the back of the last page. Thank you.

l. Where were you born?_______________________________

2. How many years of formal education? Degrees? _______ _______

3. Circle marital status: Married Single Divorced Widowed Separated Other

4. Describe as follows the people currently living with you:

Name:_________________________ Age: _____ Relationship to you:_________________

Name:_________________________ Age: _____ Relationship to you:_________________

Name:_________________________ Age: _____ Relationship to you:_________________

Name:_________________________ Age: _____ Relationship to you:_________________

Others: _____________________________________________________________________

5. Circle job status: Employed Unemployed Student Retired Disabled

6. Describe your present and/or last job: __________________________________________

7. List hobbies or areas of special interest: _________________________________________

8. Describe your religious/world views: ___________________________________________

______________________________________________________________________________

9. Please give us name and phone number of who to contact in case of an emergency: _______________

___________________________________________________________________________

Past Medical History

Hospitalisations/Surgeries:

Start with your earliest hospitalization or major surgery and continueto the present

Date Reason for hospitalization/surgery Name& town of hospital

___/___/___ _______________________________ ______________________

___/___/___ _______________________________ ______________________

___/___/___ _______________________________ ______________________

___/___/___ _______________________________ ______________________

___/___/___ _______________________________ ______________________

___/___/___ _______________________________ ______________________

Outpatient Medical History:

Start with your earliest reasons for which you sought medical care (aside from minor colds , scrapes , routine care ).

Date Reason for Medical Visit

___/___/___ ____________________________________

___/___/___ ____________________________________

___/___/___ ____________________________________

___/___/___ ____________________________________

___/___/___ ____________________________________

List your immunisations/vaccines in the last ten years, beginning with the first or earliest:

Date Type of immunisation Date Type of immunisation

___/___/___ __________________ ___/___/___ __________________

___/___/___ __________________ ___/___/___ __________________

FOR WOMEN ONLY:

Date of last pelvic exam: ___/___/___ Number of times pregnant:_______ Number of live births:___

Number of miscarriages/abortions_______ Last normal period: ___/___/___ Form of birth control:___________ Number of days normally from one period to the next_____ Date of your last mammogram: ___/___/___

Prescription Medications/Supplements:

List only medicines that have been prescribed for you.

Name of Medication/Supplement Usual Dose & Frequency DateStarted

_____________________ __________________________ ____________

______________________ __________________________ ____________

______________________ __________________________ ____________

______________________ __________________________ ____________

______________________ __________________________ ____________

Non-Prescription Medications/Supplements:

(Vitamins, Herbs, illicit etc.):

Name of Medication Usual Dose & Frequency Date Started

______________________ __________________________ ____________

______________________ __________________________ ____________

______________________ __________________________ ____________

______________________ __________________________ ____________

Allergies/Intolerances:

List all allergies and intolerances to medication, food, supplements, or anything in your environment: __________________________________________________________________________________

General Health Habits:

1. Do you use tobacco? Yes No

2. Have you ever felt a need to cut down on your drinking of alcohol? Yes No

3. Have you ever felt annoyed by someone criticizing your drinking behavior? Yes No

4. Have you ever felt guilty about drinking or other drug use? Yes No

5. How much regular coffee do you drink?_____________

6. What changes if any in your diet are you making to improve your health? _______________________

___________________________________________________________________________________

7. Do you wear seat belts? Yes No

8. Have there been any major changes in your life recently? (Deaths, moves, job changes, etc.) Yes No

If yes please briefly describe: ___________________________________________________________

9. Have you had more than one sexual partner in the past six months? Yes No

10. Have you any concerns about having AIDS or at being at risk for AIDS? Yes No

Family Medical History:

A) Circle all the following conditions which a blood relative has had (Include uncles, aunts, and grandparents):

Heart Disease / Stroke / Alcoholism / Depression / Mental Illness / Diabetes /Breast Cancer / Colon Cancer / Other Cancer:______________________ / Glaucoma / Kidney Disease / Genetic Disease_____________ / Other Noteworthy Medical Conditions: _____________________________

B) List immediate family members who have died:

Relationship Age at Death Cause of Death

__________________ _____ _______________

__________________ _____ _______________

__________________ _____ _______________

Other Health Care Practitioners:

Give the names and titles of all the health care practitioners you've seen during the last year: ____________________________________________

_________________________________________________________________________________________________________________

Review of Personal Systems:

Put an X by the items that you've had during the last year; please circle those items that you especially want to address at this time.

GENERAL: Fatigue___Weight loss___Unexplained fever___Sleeping problems___Snoring___Allergic reactions___Family problems___

UPPER AIRWAYS AND LUNGS: Nasal or sinus congestion___Post nasal drip___Hay fever___Voice change___Shortness of breath___Cough___Wheezing___Infection, serious or frequent___Sore throat___

SKIN: Rash___Hives__Acne___Infection___Itching___Swollen glands___Lumps___Change in skin___

STOMACH/DIGESTION: Appetite loss____Swallowingtrouble___Indigestion/heartburn___Nausea/vomiting___Jaundice/brown urine___Pain/discomfort___Excessive as/bloating___Constipation___Diarrhea___Blood in stools___Hemorrhoiids/rectal pain___Change in bowel habits___

URINATION/GENITALS: Change___Discomfort___Trouble starting to urinate___Unwanted loss of urine___Sudden need to urinate___Pain on urination___Sexual dysfunction___Concerns___Abnormal discharge___Pain on intercourse___Itching/dryness___Frequent nighttime urination___

HORMONES/BLOOD: Intolerance to cold___Hot flashes___Increased perspiration/sweating___Menopausal symptoms___Premenstrual problems___Easy bruising___Abnormal bleeding___Muscle spasms___Irregular/excessive periods____

HEART/CIRCULATION: Chest tightness/heaviness/pain___Heart fluttering/racing/palpitations___Leg pain aggravated by exercise___Poor circulation___Blood pressure concern___Fainting__ Dizziness___

NEUROLOGICAL/PSYCHOLOGICAL: Memory loss___Walking/coordination loss___Strength/coordination loss___Tingling/burning sensations___Numbness___Shaking/tremor___Chronic pain___Concentration problems___Irritability increase___Lack of normal pleasure___Suicidal thoughts___Phobias/unusual concerns___Anxiety/lowself-esteem___ Feelings of Hopelessness/despair ___ Unusual thoughts__ Significant loss (death, job, divorce, financial etc.)____

VISION/HEARING: Pain___Change___Blurring/Doubling___Ringing/buzzing____

HEAD/NECK/SPINE: Headaches___Stiff/sore neck___Backache___Recent injury____

JOINTS/EXTREMITIES: Swelling/pain___Redness/warmth___Varicose veins___Reduced movement___Nail/foot problems____

OTHERS NOT LISTED: _____________________________________________________