Name:
__________________________________
Date: _________________
Please
fill out the following questionnaire prior to your first appointment
if
possible.
Previous
physician (if any): _________________________________________
Address
of previous physician or clinic:
_______________________________________________________________________
_______________________________________________________________________
Please
list all of your medications including the dosages and frequency:
Medication Name Dosage Times/day__
1._______________________________________________________________
2._______________________________________________________________
3._______________________________________________________________
4._______________________________________________________________
5._______________________________________________________________
6._______________________________________________________________
7._______________________________________________________________
8._______________________________________________________________
Do you have any allergies to
medications? Yes
□ No □
If so, please list
medication and reaction:
_______________________________________________________________________
_______________________________________________________________________
Do
you have any of the following health problems?
Eyes:
Glaucoma
□ Cataracts
□
Macular degeneration □
Other_______________
Ears:
Hearing
□ Other_______________
Allergies
Hay
fever □
Food
□
Other_________________
Bones & Joints:
Back pain □
Arthritis □
Fractures □
Osteoporosis □
Other_________________
NAME:
___________________________________________________
Lungs:
Asthma
□
Emphysema □
Pneumonia □
Other_______________
Heart:
Heart attack □
Angina □
Chest pain □
Murmur □
High blood pressure □
Other_______________
Brain:
Memory
problems □
Stroke □
Seizures
□ Other_______________
Endocrine:
Diabetes
□ High cholesterol □
Thyroid
□ Other_______________
Digestive tract:
Diarrhea
□
Constipation □
Bleeding
□
Ulcers □
Polyps
□
Colitis □
Other_______________
Urinary tract:
Bladder infections □
Prostate problem □
Incontinence □
Other_______________
Woman’s
Health: Pregnancies?__________
Abnormal Pap □
Excessive periods □
Spotting □
Breast lumps □
Other_______________
Skin:
Rash
□ Skin
cancer □
Eczema
□
Psoriasis □
Other_________________
General:
Fever
□
Sweats □
Sleeping problem □
Weight gain □
Weight loss □
Anxiety □
Depression □
Other_______________
Blood:
Anemia
□
Bleeding □
Cancer or tumors:
__________________________________________________
Infections:
Tuberculosis □
Rheumatic fever □
Sexually transmitted □ Chicken
pox □
Diseases
Have you had any of the
following vaccines?
Approx. year:
Flu
□
___________
Pneumonia vaccine □
___________
Tetanus □
___________
MMR
□
___________
Other: ______________________________________
Have you had any
surgeries? Yes □
No □
If so, please list:
____________________________________________
_________________________________________________________________
_________________________________________________________________
NAME: ___________________________________________________
Habits:
1. Have you ever
smoked?
Yes
□ No □
If so, how many years?
_____ When did you
quit? ____________
How many packs/day? ________
2. Do you drink
alcohol?
Yes □ No □
If so, how many years?
______
How many drinks per week on
average? ______________
3. Do you use any
recreational drugs? Yes □
No □
4. Are satisfied with
your current weight? Yes □
No □
5.
When did you last see your dentist? _______________________________
6.
How many caffeinated beverages (coffee, tea, cola or other)
per day? ___________
7. How many times a
week do you exercise? ______________
8. Do you feel that
your stress level
is too
high?
Yes □ No □
Social
history:
Occupation
____________________________________________________________
Are
you: single □
married
□
divorced
□
Is
your partner of the:
same sex □
opposite sex □
no partner □
Do
you have children? Yes □
No □
Do
you have Durable Power of Attorney for Healthcare?
Yes □ No □
If so, name of person named
as durable power:
_______________________________________________________________________
Phone
number: ________________________________________________________