Medical Questionnaire
Personal Information
E-Mail:*
  		Valid e-mail is required
First Name:*
 
Last Name:*
 
Address Line 1:*
 
Address Line 2:
 
City:*
 
State:*
 
Zip Code:*
 
Marital Status:
 
Gender:
 
Date of Birth:
 
Phone:*
 
Height:*
 Weight:*
  
Reason for your visit:*
 Previous Condition?*
            Yes
            No
  
Patient History
Who was your previous primary care physician (list name, address & phone)?
*
 
List all medications & supplements that you are currently taking.
*
 
List all medications & supplements that you have previously taken.
*
 
List all drug allergies you currently have.
*
 
List all other allergies you currently have.
*
 
Date & reason of your last doctor visit.
*
 
Date & conditions of your past surgical procedure(s).
*
 
Date & conditions of your past hospitalization(s).
*
 
How is your overall health? Please explain.
*
 
How is your energy level?.
*
 
Explain your exercise routine. How often?.
*
 
How is your mental alertness?.
*
 
List the diseases that run in your family.
*
 
Substance abuse? Please describe.
*
 
Do you suffer from depression? Please describe.
*
 
Alcohol: Drinks per week? Drinks per day? Please describe.
*
 
Smoking: Packs of cigarettes per day? Please describe.
*
 
Specific Disorders (Check all that apply)
Measles:
 Mumps:
 Chicken Pox:
Whooping Cough:
 Scarlet Fever:
 Pnemonia:
Bursitis:
 Polio:
 Reduced Vitality:
Arteriosclerosis:
 Stroke:
 Heart Problems:
Seizure Disorders:
 Anxiety Disorder:
 Elevated PSA Level:
Anemia:
 Bulimia:
 Anorexia:
Cirrhosis of the Liver:
 Renal Failure:
 Colitis:
Herpes:
 Syphilis:
 HIV Disease:
Chlamydia:
 Angina Pectoris:
 Tachycardia:
Hypertension(high blood presure):
 Hypotension(low blood presure):
 Tuberculosis:
Breathing Problems:
 Asthma:
 Chronic Bronchitis:
Chronic Cough:
 Emphysema:
 Chronic Sinusitis:
Allergic Sinus problem:
 Chronic Allergic Rhinitis:
 Sinus Headaches:
Chronic Colds:
 Female Menopause:
 Andropause - decreased potency:
Nervous Disturbances:
 Loss of Memory:
 Psychiatric Disturbances:
Decreased Sexual Potency:
 Sleep Disturbances:
 Dizziness:
Chronic Migraine:
 Meningitis:
 Jaundice:
Epilepsy:
 Ear Infection:
 Hearing Loss:
Nausea:
 Rectal Bleeding:
 Burning of Urination:
Breast Cancer:
 Cervical Cancer:
 Ovarian Cancer:
Prostate Cancer:
 Enlarged Prostate:
 Bladder Cancer:
Liver Disease:
 Kidney Disease:
 Hyperthyroidism:
Thyroid Disease:
 Hypothyroidism:
 Lupus Erythematosus:
Scleroderma:
 Epistaxis (Nosebleed):
 Chicken Pox:
Bacterial/Fungal Infection:
 Hepatitis:
 Glaucoma:
Loss of Appetite:
 Rapid Weight Gain:
 Rapid Weight Loss:
Digestive problem:
 Acid Indigestion:
 Stomach Ulcers:
Overweight problem:
 Pancreatitis:
 Pancreatic Insufficiency:
Leg Cramps:
 Swollen Ankles:
 Varicose Veins:
Joint Pain:
 Back Pain:
 Arthritis:
Leg Ulcers:
 Arms/Legs tingling sensation:
 Hands/Legs falling asleep:


Powered by Elbowspace.com
Create a form with this template