Medical Appointment System

Step 1: Personal Health History

Full Name (Last, First, M.I.)

Sex

M

F

Date of Birth

Marital Status

Single

Partnered

Married

Separated

Divorced

Widowed

Previous or Referring Doctor

Date of Last Physical Exam

Childhood Illnesses

Measles

Mumps

Rubella

Chickenpox

Rheumatic Fever

Polio

Immunizations and Dates

Tetanus

Hepatitis

Influenza

Pneumonia

Chickenpox

MMR (Measles, Mumps, Rubella)

Medical Problems Diagnosed by Other Doctors

Surgeries

Year	Reason	Hospital

Other Hospitalizations

Year	Reason	Hospital

Have you ever had a blood transfusion?

Yes

No

Step 2: Medications & Allergies

Prescribed & Over-the-Counter Drugs (including vitamins and inhalers)

Name the Drug	Strength	Frequency Taken

Allergies to Medications

Name the Drug	Reaction You Had

Step 3: Health Habits & Personal Safety

All questions in this section are optional and will be kept strictly confidential.

Exercise

Sedentary (No exercise)

Mild exercise (i.e., climb stairs, walk 3 blocks, golf)

Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)

Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)

Diet

Are you dieting?

Yes

No

Physician prescribed medical diet?

Yes

No

# of meals per average day

Rank salt intake

Rank fat intake

Caffeine

None

Coffee

Tea

Cola

# of cups/cans per day

Alcohol

Tobacco

Do you use tobacco?

Yes

No

Cigarettes – pks./day

Chew – #/day

Pipe – #/day

Cigars – #/day

# of years used

Or year quit

Drugs

Do you currently use recreational or street drugs?

Yes

No

Have you ever given yourself street drugs with a needle?

Yes

No

Personal Safety

Do you live alone?

Yes

No

Do you have frequent falls?

Yes

No

Do you have vision or hearing loss?

Yes

No

Step 4: Family Health History

Family Member	Age	Family Member	Sex
Father		Children	M F
Mother			M F
Sibling	M F
	M F
	M F		Grandmother Maternal
	M F		Grandfather Maternal
	M F		Grandmother Paternal
	M F		Grandfather Paternal

Step 5: Other Problems

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.

I confirm the above information is accurate and complete.

Health History Questionnaire