Personal Health History

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Personal Health History Today s Date: Last Name: First Name: MI: Address: (Street Address) (City) (State) (Zip) Birthdate: Age: Marital/Partner Status: Home Phone: Work Phone: Cell Phone: Employer: Job Title: Do you have children? Yes No If so, how many? Ages? Do they live with you? Yes No Personal Health History Check illnesses that you are experiencing, either currently or in the past. Give details on the back of this sheet: Illness Yes Illness Yes Illness Yes Addictions Alcoholism Allergies Arthritis Asthma/Hay Fever Anemia/Blood Disorder Blood Transfusion Broken Bones Bowel Disease Chicken Pox Constipation Diarrhea Cancer (Describe type) Cataracts Chronic Chronic Cough Chest Pain Depression Diabetes Deafness/Hearing Difficulty Drug Abuse Bronchitis/Emphysema Epilepsy/Seizures Ear/Nose/Throat Problems Fainting/Dizziness Glaucoma Gall Bladder Disease Glasses/Contact Lens High Blood Pressure High Blood Cholesterol Hemorrhoids Head Injury Hernia Heart Disease Jaundice Joint Problems Kidney/Bladder Disease Mumps Measles Nervous/Emotional Disorders Rheumatic Fever Sexually Transmitted Skin Diseases Diseases Stroke Tuberculosis (TB) Ulcer/Stomach Trouble Venereal Disease (warts, herpes, HIV, syphilis) Other (Describe): Other (Describe): Page 1 of 5

Description of Personal Health History (from front of sheet) Family Health History Check any disease which affected a member of your immediate family (parent, sibling, grandparent). Specify which relative has or had the disease: Illness Yes Which Relative? Illness Yes Which Relative? Alcoholism Nervous/Mental Disorder Obesity Heart Disease Stroke Osteoporosis Breast Cancer Lung Cancer Kidney Disease Anemia/Blood Disorder Colon Polyps Drug Abuse High Blood Pressure Lung Disease Diabetes Seizures Colon Cancer Ovarian Cancer Other Cancer Liver Disease Prostate Cancer Other Current Symptoms/Health Concerns Please describe any additional symptoms or concerns that you would like to discuss with your physician: Past Surgeries/Hospitalizations List the dates and the reasons for hospitalization and/or type of surgery: Pregnancies List number of pregnancies, vaginal or c-section, and any complications. Page 2 of 5

Allergies List all substances to which you have been told you are allergic. Include medications, dyes, environmental products, etc. What was the reaction to the allergen?: Current Medications List all current medications. Include over-the-counter meds and herbal remedies: Name of Medication Dose Time of day taken 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Personal Habits What is your highest level of education (high school, college, trade school) If working, do you work full-time or part-time? FT PT Do you currently smoke tobacco? Yes No If so, how many cigarettes do you smoke each day? If you smoked cigarettes in the past, when did you stop? Describe any other tobacco use: How many alcoholic beverages do you drink per day? Per week? Describe any drug use (not medications): Page 3 of 5

Are you sexually active? If yes, men, women, or both? At what age did you become sexually active? Number of sexual partners you have had in the past: Do you practice safe sex? Yes No Do you have a Living Will (Advance Directive)? Do you have a Durable Power of Attorney for Healthcare? If so, who is it? Wellness Complete the following statement: Overall, I would rate my health as (check one box): Excellent Very Good Good Fair Poor How many days per week do you engage in some form of aerobic exercise of at least 20 minutes duration (walking, biking, swimming, exercise class, other sports)? What other types of physical activity do you engage in on a regular basis? If you are unable to be active on a regular basis, please describe the reasons why: Are you on a special diet? Yes No If yes, what type of special diet? Do you pay special attention to the following in your diet? Yes No Fat intake Salt intake Increase in fruits and vegetables Increase in high fiber foods How many caffeinated beverages do you drink per day? How much has your weight changed in the past year? Gain/Loss lbs. Coping and Stress Overall, how well do you feel you are coping with life? Please describe any symptoms you have that you feel are related to the stress in your life: What do you do on a regular basis to better cope with stress? Page 4 of 5

Personal Safety Check the boxes that apply to you: Yes No Do you wear a seatbelt every time you are in a car? Do you wear sun screen or protective clothing when you are in the sun? Do you have working smoke detectors in your home? Do you have a carbon monoxide detector in your home? Do others smoke in your home? Preventative Medical Care Check the boxes that apply to you: Yes No If yes, when/where? Physical exam in past 5 years Cholesterol check in the past 2-5 years Blood pressure check in the past year Dental exam in the past year Vision exam in past 3 years Colon cancer screening in past 1-3 years (over age 50) Women: Pap smear exam in past 1-3 years Mammogram in past 1-2 years Breast self-exam monthly Bone density exam in past 2 years Men: Testicular self-exam monthly PSA (blood test for prostate cancer) in past 1-2 years Immunizations: Childhood immunizations (when you were young) Pneumonia vaccine Flu shot - yearly Hepatitis A vaccine (2 shots) Hepatitis B vaccine (3 shots) Tetanus/Diptheria every 10 years Adacel (Tetanus/Diptheria/Whooping Cough) Zostavax (Shingles vaccine) Health Interests List any health/wellness topics for which you would like more information: Thank you for working with us to improve your health. (Revised 9/2013) Page 5 of 5

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