Health History Questionnaire

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Health History Questionnaire Page 1 of 8 Thank you for choosing Martin s Point to be your partner in health. To help us give you the highest-quality care, please answer the questions on this form as well as you can. Please bring the completed form with you to your appointment. Your provider may ask some follow-up questions when entering this information into your medical record. If you are unsure of an answer, please write in a question mark (? ). If the question does not apply to you, please write in N/A. You may also add more information in the margins, if needed. Thank you! Last name: Middle: First name: Preferred name: Gender: Date of birth: / / Social Security number: Address: Street: City: State: Zip Code: Phone numbers: Home: Mobile: Work: Email address: How do you prefer we contact you? Home phone Work phone Mobile phone Mail Usual provider: Language: Race: (Examples: White, Black or African American, Asian, etc.) Ethnicity: (Examples: French, Italian, Mexican, Puerto Rican, Chinese, etc.) Refused Marital status: Married Single Divorced Separated Widowed How did you hear about us? Advertising Word of mouth Primary care physician Patient in practice Specialist physician Hospital Insurance company Other (specify):

Page 2 of 8 Are you currently taking any prescribed or over-the-counter medication(s)? No Yes (If yes, please list your medication information below.) Medication name: Dose (mg): How do you take your medication? Date Started: 1 By mouth Other 2 By mouth Other 3 By mouth Other 4 By mouth Other 5 By mouth Other 6 By mouth Other 7 By mouth Other 8 By mouth Other 9 By mouth Other 10 By mouth Other 11 By mouth Other 12 By mouth Other 13 By mouth Other 14 By mouth Other 15 By mouth Other

Page 3 of 8 Do you have any allergies? No Yes (If yes, please list allergy information below.) Allergy: Last time you had a reaction? Date: Symptom(s) experienced: 1 2 3 4 5 6 Advanced Directive: No Yes Occupation: Education: Less than Grade 8 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 College, 2-year College, 4-year Post-graduate Do you live alone or with others? Alone With others Number of children: Diet: Regular Vegetarian Vegan Gluten-free Carbohydrate Cardiac Diabetic Specific Exercise level: Low Medium High

Page 4 of 8 General stress level: Low Medium High Sporting activities: Hobbies/ activities: Smoking status: Never smoked Former smoker Currently smoke every day Currently smoke some days Current smoker how much? Occasional (Not every day) Moderate (Less than one pack a day) Heavy (More than one pack a day) Tobaccochewing history: None Once a day 2 4 times a day times a day How many years have you used tobacco? Alcohol intake: None Moderate Women: 1 drink a day Men: 2 drinks a day Occasional Women: Less than 1 drink a day Men: Less than 2 drinks a day Heavy All: 5+ drinks on same occasion, at least 5 times in the last month Caffeine intake: None Occasional Less than 1 caffeinated drink a day Moderate Heavy 1 2 caffeinated drinks a day More than 2 caffeinated drinks a day Do you use recreational/illicit drugs? Are you sexually active? No Yes How often do you use protection against sexually-transmitted diseases? (Example: condoms or dams) Always Usually Never

Page 5 of 8 Do you perform a breast self-exam monthly? No Yes Do you routinely use a seat belt? No Yes Do you currently have a smoke or carbon monoxide detector in your home? No Yes Do you routinely use sunscreen? No Yes Do you routinely use insect repellent? No Yes Are you legally blind in one or both eyes? No Yes Do you have difficulty hearing or are you deaf in one or both ears? No Yes Are there guns in your home? No Yes Do any of your biological family members have any diseases/conditions? No Yes (If yes, list disease(s)/condition(s) information below.) Check disease (if applicable): Relation to patient: Age of family member when disease began: If disease was terminal, age of family member at time of death: Alcoholism Alzheimer s disease Asthma Stroke COPD Coronary artery disease

Page 6 of 8 Check disease (if applicable): Relation to patient: Age of family member when disease began: If disease was terminal, age of family member at time of death: Dementia Diabetes Disorder of endocrine system Glaucoma High cholesterol High blood pressure Kidney disease Melanoma Breast cancer Colon cancer Lung cancer Have you had any previous surgeries? No Yes (If yes, list surgery information below.) Check surgery (if applicable): Ablation (cardiac) Ablation (endometrial) Ablation (venous) Amputation Appendectomy Arthroscopic surgery Back surgery Breast augmentation Coronary angioplasty Coronary angioplasty with stent Cataract surgery

Page 7 of 8 Check surgery (if applicable): Cesarean section Gall bladder surgery Circumcision Cleft palate/lip repair Colposcopy Coronary artery bypass (CABG) D & C Ear/myringotomy tube placement Eye surgery Frenulectomy Bariatric surgery Gastric surgery Gastrostomy tube replacement Joint replacement Knee surgery LEEP Labial adhesions surgery Lumpectomy Mastectomy (complete) Mastectomy (partial) Neck surgery Neurosurgery Nissen fundoplication Oophorectomy Orthopaedic surgery Other Pacer/AICD placement Prostate surgery Prostatectomy Pyloric stenosis repair Reconstructive surgery Rhinoplasty Septoplasty Splenectomy Strabismus surgery Thyroid surgery Tonsils/adenoid Tracheostomy Tubal ligation Undescended testicle surgery VP shunt placement Valve replacement Vasectomy Have you had any past medical issues or conditions? No Yes (If yes, list any past medical issue or condition information below.) Check medical issue/condition (if applicable): ADD/ADHD Acne Alcohol/drug abuse Allergy (hay fever) Anemia Anxiety Arthritis (osteoarthritis) Arthritis (rheumatoid) Asthma Autism Blood clot (leg) Blood clot (lung) Blood transfusion Breast lump (benign) Cancer (breast) Cancer (cervical) Cancer (colon) Cancer (other type)

Page 8 of 8 Check medical issue/condition (if applicable): Cancer (ovarian) Cancer (skin) Colon polyp Concussion Constipation Coronary artery disease Depression Diabetes type 1 Diabetes type 2 Diverticulosis Emphysema/COPD Fractures (broken bones) GERD/heartburn Gallbladder disease Glaucoma Gout Gynecological condition (endometriosis) Gynecological condition (fibroids) Gynecological condition (other) Headaches Heart murmur Hepatitis (other) Hepatitis B Hepatitis C High blood pressure High cholesterol Hip fracture Irritable bowel syndrome Kidney disease/failure Kidney stones Liver disease MRSA infection Osteoporosis Pneumonia Prostate enlargement Recurrent ear infections Seizure/epilepsy Skin condition (abnormal moles) Skin condition (eczema) Skin condition (psoriasis) Sleep apnea Stomach ulcer Stool incontinence Stroke Thyroid (hyper) Thyroid (hypo) Thyroid (nodule) Urinary tract infections (UTI) Urinary (frequency) Urinary incontinence

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