All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Name:
DOB:
Marital Status:
Personal Physician:
Height:
Weight:
Your Present Medical Problem (nature and duration):
Personal Health History
Date of Last Physical Exam
Dr.
Date of Last Chest X-Ray
Date of Last Chest EKG
Current Medications/Dose:
List any medical problems that other doctors have diagnosed or any serious injuries or accidents you have had in the past:
Surgeries:
Year
Type of Surgery (eg. gallbladder or appendix removed)
Hospital
Other hospitalizations:
Year
Reason
Hospital
Have you ever had a blood transfusion?
Are you presently taking any of the following medications? If yes, please give name and dosage
Aspirin/Bufferin/Anacin:
Strength:
Frequency Taken
Blood Thinning Medication:
Strength:
Frequency Taken
Birth Control Pills:
Strength:
Frequency Taken
**If you are on Coumadin – please discuss this with the Dr. prior to surgery**
Allergies to medications:
Name the Drug
Reaction You Had
Do you have a latex allergy?
HEALTH HABITS
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.
Caffeine
Alcohol
Tobacco
Drugs
# of cups/cans per day?
Do you drink alcohol or beer?
How many drinks per week?
Do you use tobacco?
pks./day:
#/day
#/day
#/day
# of years
Or year quit
Do you currently use recreational or street drugs?
If so, please list all drugs:
FAMILY HEALTH HISTORY
Please list any blood relative who has had any of the following (please give relationship and details)
Birth Defects:
Bleeding Tendency:
Breast Cancer:
Colon Cancer:
Other Cancer:
Congenital Heart Disease:
Diabetes:
Heart Attack/Heart Disease:
High Blood Pressure:
High Fevers with Surgery:
Stroke:
Other:
MEDICAL HISTORY
PLEASE INDICATE IF YOU CURRENTLY HAVE OR HAVE HAD ANY OF THE FOLLOWING:
(Please give date of occurrence)
Stroke:
Migraine
Epilepsy or Convulsions
Heart Attack
Chest Pains, Angina
Chest Palpitations or Fast or Irregular Heart Beat
Heart Murmur
Congenital Heart Disease
Rheumatic Fever
Bronchitis or Chronic Cough
Asthma
Hay Fever
Pneumonia
Tuberculosis
Emphysema
Shortness of Breath
Other Lung Problems
Stomach Ulcers
Colitis
Rectal Bleeding
Colon Polyps
Hemorrhoids
Heavy Skin Scarring
High Blood Pressure
Low Blood Pressure
Anemia
Jaundice
Liver Disease
Hepatitis
Bladder Infection
Kidney Disease
Diabetes
Low Blood Sugar
Thyroid Problems
Cancer
Leukemia
Bleeding Tendency
Depression
Arthritis
Back Pain or Injury
Sciatica
AIDS
Other
In the past 60 days have you donated blood at another center?
In the past 7 days have you donated plasma at another center?
If you answered yes to either, please provide the date you last participated as a blood or plasma donor:
WOMEN ONLY
Date of last menstruation:
Period every
days
Number of pregnancies
Number of live births
Are you pregnant or breastfeeding?
Children’s Ages:
IF YOU THINK YOU MAY BE PREGNANT, PLEASE LET YOUR PHYSICIAN KNOW. THIS IS IMPORTANT BEFORE WE ORDER ANY X-RAYS OR PERFORM ANY SURGICAL PROCEDURES
Do you have or have you had:
Breast lumps?
Breast biopsies?
Other breast surgery?
Diagnosis of breast cancer?
Nipple Discharge?
Painful or tender breasts?
Blood relatives with breast cancer?
By signing below, I certify that this health history questionnaire has been filled out honestly and is accurate to the best of my knowledge. I have notified staff if there is a question that I don't understand and it has been sufficiently clarified.
