Health Questionnaire
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- Kathleen Terry
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1 Health Questionnaire If you do not ask the right questions you do not get the right answers. A question asked in the right way often points to its own answer. Asking questions is the A-B-C of diagnosis. Only the inquiring mind solves problems. Edward Hodnett George J. Juetersonke, D.O., P.C American Drive Colorado Springs, CO Date: Referred by: Pharmacy: Internet I. Personal Information Name: Age: Birthplace: Date of Birth: Marital Status: o Single o Married o Widow(er) o Separated o Divorced o Partnered Children: Occupation: Hobbies: Pets: Education: What are your health goals? II. General Health Information - (Please bring copies of recent lab) Height: Weight: Blood Pressure: When last taken: When and where did you have your last physical checkup? Name of family physician Present illness / Main concern (single worst): 1
2 List other concerns in order of severity: Date or age main symptoms began? Was there a trigger? Began where? How often do episodes occur? How long do they last? o Yes o No Free of symptoms? When? What factors do you know or suspect from your own experience cause your symptoms or make them worse? What makes your symptoms better? What kind of medical doctors or specialists have you seen for your main complaint? What was your diagnosis, what advice was given? Have you recently been treated by any of these types of practitioners? o Yes o No Psychologist o Yes o No Homeopath o Yes o No Biofeedback o Yes o No Osteopath o Yes o No Acupuncturist o Yes o No Naturopath o Yes o No Chiropractor o Yes o No Reflexologist o Yes o No Nutritionist o Yes o No Kinesiologist o Yes o No Hypnotist Check Diagnostic Studies/Procedures you have had: Biopsy: Date: Results: Blood test(s): Date: Results: Cholesterol: Date: Results: Body Scan(s): Date: Results: Bone Density: Date: Results: Colonoscopy: Date: Results: Electrocardiogram: Date: Results: Hearing Test: Date: Results: Mammogram: Date: Results: MRI: Date: Results: PAP: Date: Results: PSA: Date: Results: X-rays: Date: Results: Vaccines Flu: Date: TB Test Date: Pneumonia: Date: Menningitis: Date: Shingles: Date: Tetanus: Date: HPV: Date: 2
3 Medications Name Dose Frequency Duration Supplements/Vitamins Name Dose Frequency Duration Allergy or Adverse Reactions (Medications or supplements only) Substance Reaction Surgical History Surgery Date Reason for Surgery
4 Immediate Family Instructions: Please include all information you know of related to the following areas. What is your ancestry / ethnicity? Paternal Maternal Father Mother Brother Sister Grandfather Grandmother Grandfather Grandmother Age if living Age at death Cause of death Type of work Asthma Allergy Hives Eczema Blood clots Weight problem Tobacco use Alcohol abuse Mental Illness Cancer Diabetes Hypertension Heart problem High cholesterol Thyroid disease Ulcers Arthritis Osteoporosis Other Ears, Nose, Throat o Yes o No Do you have ringing or buzzing in your ears? o Yes o No Do you have allergies? Chemical Seasonal Animals Dust Mold o Yes o No Do you have any nasal polyps? o Yes o No Have you had sinus infections? Within the last year? o Yes o No Hearing Aid? o Yes o No Do you have any decayed painful teeth or bleeding gums? o Yes o No Do you have persistent sores in your mouth? o Yes o No Do you have trouble swallowing foods? o Yes o No Do you often have hoarseness? o Yes o No Do you floss everyday? o Yes o No Do you have filling in your teeth? Which type? 4
5 Dermatologic o Yes o No Do you have a chronic skin condition? o Yes o No Do you tend to have dandruff? o Yes o No Fungus? o Yes o No Hair falling out? o Yes o No Do your nails split easily? Eyes o Yes o No Dryness? o Yes o No Sensitive to light? o Yes o No Wear glasses or contacts? o Yes o No Glaucoma? o Yes o No Cataracts? o Yes o No Macular degeneration? o Yes o No Difficulty seeing at night? Headaches o Yes o No Migraine? Check items associated with headache: o Yes o No Sinus? o Loss of sight o Light sensitivity o Vomiting o Yes o No Tension? o Dazzling lights o Visual disturbance o Neck / Shoulder pain o Diarrhea o Noise sensitivity o Flushing o Tender or painful skin o Queasy stomach o Chilly sensation o Tearing of eye o Abdominal pain o Nasal drip o Nausea Endocrine o Yes o No Do you have chronic fatigue? o Yes o No Do you have insomnia? o Yes o No Do you obtain 8 hours of sleep each night? If not, how much? o Yes o No Have you lost or gained more than ten pounds in the last year? Lowest adult weight Lbs Age Highest adult weight Lbs Age o Yes o No How much would you like to weigh? Lbs o Yes o No Have you ever had thyroid trouble? Low? High? o Yes o No Have you had hypoglycemia? o Yes o No Have you ever been diagnosed with metabolic syndrome or insulin resistance? Hematology o Yes o No Have you had a low white blood count? o Yes o No Have you ever been anemic? (Had low red blood count.) o Yes o No Have you taken iron pills previously? o Yes o No Do you bruise easily? o Yes o No Have you noticed swelling lymph glands in your neck, armpits or groin lately? o Yes o No Have you had blood clots? 5
6 Chest Cardiovascular o Yes o No Have you had asthma? When? o Yes o No Have you ever been told you have emphysema or chronic bronchitis or another disease? o Yes o No Do you get out of breath easily? o Yes o No Do you have chest tightness? o Yes o No Have you recently had episodes of chest pain lasting more than one minute? o Yes o No Have you ever had a heart attack? o Yes o No Have you had an abnormal EKG? o Yes o No Does your heart race or skip? o Yes o No Have you had a heart murmur? o Yes o No Have you had swelling in your feet or ankles? o Yes o No Do you have high blood pressure? How far can you walk vigorously before becoming short of breath? Gastrointestinal o Yes o No Were you ever treated for ulcers? o Yes o No Have you had black bowel movements? o Yes o No Have you had blood in your stools, even in small amounts? o Yes o No Have you ever had yellow jaundice or hepatitis? Check symptoms that apply: o Heartburn o Indigestion o Belch frequently o Bloating o Flatulence o Stomach aches o Cramping o Queasy Stomach o Constipation o Use laxatives o Diarrhea o Anal itching o Mucus in stools o Gallbladder trouble o Hemorrhoids o Nausea o Abdominal pain Urinary o Yes o No Do you usually have to get up at night to urinate? How many times? o Yes o No Do you void only small amounts of urine each time you go? o Yes o No Does it hurt to urinate? o Yes o No Do you lose urine when you cough or sneeze? o Yes o No Have you ever had kidney stones? What kind? Sexually attracted to: o Male o Female o Both Neurology o Yes o No Have you had head injuries? o Yes o No Have you ever had blackout spells? If so, when? o Yes o No Have you ever had seizures (convulsions)? If so, when? o Yes o No Have you ever lost your ability to speak? o Yes o No Are there times when you have trouble thinking clearly or explaining what you mean? o Yes o No Were you ever told you had learning disabilities or dyslexia? 6
7 Skeletal o Yes o No Do you have arthritis? What kind? o Yes o No Do you have fibromyalgia? o Yes o No Do you have muscle spasms, pain, fatigue? o Yes o No Do you experience restless legs? Women Only Preimenopause/Menopause Symptoms Check all symptoms you are currently experiencing: o Hot flashes o Irregular or absent menstrual cycles o Lack of sexual desire/orgasm o Memory loss o Mood swings o Night sweats o Skin wrinkles o Vaginal dryness o Other Sexual/Reproductive First day of last menstrual period? o Yes o No Do you have heavy bleeding and/or painful menstrual cycles? o Yes o No Have you been diagnosed with PMS (Premenstrual Syndrome) or PMDD (Premenstrual Dysphonic Disorder? o Yes o No Have you been diagnosed with PCOS (Polycystic Ovarian Syndrome) o Yes o No Are you currently using contraception? If yes, what method? o Yes o No Are you trying to get pregnant? o Yes o No Have you had more than 1 miscarriage? o Yes o No Have you ever had a high risk pregnancy, premature delivery, or other complication of pregnancy/delivery? Describe: How many times have you been pregnant? How much did your largest baby weigh? o Yes o No Are you currently sexually active? o Yes o No Is intercourse painful? o Yes o No Have you ever had an abnormal pap smear? If yes, when Results o Yes o No Have you ever been diagnosed with Genital Herpes or HPV (Human Papilloma Virus)? o Yes o No Have you ever been treated for other sexually transmitted infections? o Yes o No Are you currently experiencing abnormal vaginal discharge? o Yes o No Are you experiencing low libido/lack of sexual desire? Men Only o Yes o No Discharge from penis? Sores on penis? o Yes o No Lump or pain in testicle(s)? o Yes o No Do you have a decrease in libido? o Yes o No Are your erections less strong? o Yes o No Inability to achieve or sustain an erection? 7
8 Headache, Nerve, Muscular or Skeletal Pain o Yes o No Please color on the picture where you have pain or other symptoms. Include symptoms of pain, numbness or tingling. o Yes o No Are there foods that make your symptoms better? Worse? Explain: o Yes o No Do you feel better if you skip a meal? o Yes o No Have you ever fasted? When? For How Long? o Yes o No Are there foods you occasionally crave? Explain: If you could not eat for several days, what food or foods would you miss the most? Are most of your meals at home at restaurants Please list what you typically eat for: Breakfast: Lunch: Dinner: Snacks: Beverages: 8
9 Personal Habits Do you consider your health to be: o Excellent o Good o Fair o Poor How often do you exercise? o At least 3 times a week o Occasionally o Rarely o Never If you exercise, what do you do? For how long and how often? Tobacco Use o Yes o No Do you currently smoke cigarettes? If yes, how many per day? When did you start? If you do not currently smoke cigarettes, have you ever smoked? o Yes o No If yes, when did you start? How many per day? When did you stop? Do you use any other type of tobacco? o Yes o No If yes, what? Alcohol and Drug Use o Yes o No Do you drink alcohol? If yes, how many drinks do you have each week? o Yes o No Do you ever have a drink in the morning to help you get going? o Yes o No Have you ever tried to cut down on your drinking? o Yes o No Have you ever felt guilty about the amount you drink? o Yes o No Have you ever been an alcoholic? o Yes o No Do you use recreational drugs? Abuse o Yes o No Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? o Yes o No Within the last year, has anyone ever forced you to have sexual activities? o Yes o No Do you feel you are verbally or emotionally abused by someone? o Yes o No Have you had counseling for these issues? Stress Management How do you handle stress? o Very well o Moderately well o Poorly Check all the stressors, if any, that apply to you: o Family member(s) o Financial o Health issues o Job/Professional Issues What do you do to relax? o Yes o No Is your hostility easily aroused? o Yes o No Do you show aggressive impatience with anyone or anything that delays you? o Yes o No Do you get enough leisure time? o Yes o No Are you usually happy? o Yes o No Do you have too many responsibilities? o Yes o No Is your job satisfying to you? o Yes o No Is your job upsetting you? o Yes o No Are you usually satisfied with medical advice? o Yes o No Do you have periods of worry or feeling tense? o Yes o No Do you feel depressed or lonely? o Yes o No Do you have crying spells? 9
10 Health Maintenance o Yes o No Do you have carbon monoxide and smoke detectors in your home? When did you last check the batteries? o Yes o No Do you wear seat belts ALL of the time? o Yes o No Do you talk or text on your cell phone while driving? o Yes o No Do you use sunscreen? o Yes o No Do you have an advanced directive, living will, and health care power of attorney? How many hours per week do you spend? Watching TV Internet Cell Phones/Texting Computer other than work Video Games/Movies Thank you for the effort put into completing your health questionnaire! The secret of the care of the patient is in caring for the patient. Francis Weld Peabody George J. Juetersonke DO PC Kim Brown RN MS NP-C 3525 American Drive Colorado Springs, CO
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