Health Questionnaire

Your Name

Physician

HMO ID #

Address

City

Mo/Year of your last medical examination

Phone

Your Age Height Weight

How would you describe your present health?

Excellent Good Fair Poor Don’t Know

Y

N

?

Check for Yes, No or ?

Has there been any change in your general health in the past year?

If yes, please describe

Have you had a serious illness, operation or hospitalization during the past five years?

If yes, please describe

Are you taking or have you recently taken any of the following:

Prescribed medications & inhalers:

Over the counter, natural or herbal preparations:

Have you ever taken Pondimin (fendluramine), Phen-Fen (phentermine) or Redux (dexphenfluramine) for weight reduction?

Has your M.D. told you to take antibiotics prior to having any type of dental procedure?

Are you allergic to any medications or drugs, latex, iodine?

Have you ever had adverse reaction to any drugs, anesthetics, sedatives, narcotics, aspirin, ibuprofen (motrin)?

Have you ever had excessive bleeding that required special treatment?

Have you been diagnosed as having any Immunodeficiency, Systemic Lupus, ARC or AIDS?

Is there a history of diabetes in your family?

Are you required, due to health, to restrict your work or activity in any way?

Are you on a special or restricted diet of any kind?

Do you use any kind of tobacco?

If so how much: per day, week, month

Do you use any kind of alcohol?

If so how much: per day, week, month?

Do you have any history of substance abuse or do you currently use recreational drugs?

For women, check all that are appropriate:

I am pregnant

I am nursing

I am taking birth control pills

Chest Pain Upon Exertion

Received Bloodtransfusion

Sleep Apnea

Migraines

Shortness Of Breath

Impaired Liver Function

Asthma

Epilepsy

High Blood Pressure

Kidney Disease

Bronchitis

Seizures

Low Blood Pressure

Impaired Kidney Function

Emphysema

Mental Health Problems

Heart Valve Prosthesis

Esophygeal Reflux

Sinus Troubles

Mitral Valve Prolapse

Hiatal Hernia

Persistent Cough

Glaucoma

Congenital Heart Lesion

G.I. Ulcers

Tuberculosis

Wear Contact Lenses

Rheumatic Fever

Anorexia Or Bulemia

Severely Impaired Vision

Heart Murmur

Irritable Bowel Syndrome

Joint Replacement Surgery

Damaged Heart Value

Colitis

Arthritis

Recurrent Infections

Heart Arrthymiia

Diabetes

Connective Tissue Disorder

Chronic Fatigue

Tachycardia

Recent Weight Loss

Heart Surgery

Radiation Therapy

Neurological Disorders

Cardiac Pacemaker

Chemotherapy

Stroke

Hepatitis Or Jaundice

History Of Cancer

Headaches

Signature of patient or legal guardian:

Date:

Reviewed By: