Name_________Male___________Female___________Race___________Date of birth__________Address_______________Married___________Separated________Divorced________Widowed________Single
Education_________years Elementary_________years High School_______Years College
Telephone Home number Work number
Social security or Medicare No. Occupation
FAMILY HISTORYWhat is your father’s (mother’s, sister’s, brother’s) state of health?
(good health, poor health, deceased)
Has he (she) had allergies (asthma, anemia, blood clotting problems, diabetes, cancer, tumor, epilepsy, glaucoma, genetic diseases, alcoholism, kidney or bladder trouble, stomach ulcer, duodenal ulcer, rheumatism or arthritis, high blood pressure, heart trouble, gout)?
How is your spouse’s health? How is your child’s (your children’s) health?
How many paternal (maternal) relatives are affected with (allergies, asthma, anemia, blood clothing problems...)?
Have you ever had eye infections (thyroid diseases, eczema, hives or rashes, bronchitis, emphysema, pneumonia, pancreatitis, liver disease, diverticulosis, hernia, hemorrhoids, neuralgia or neuritis, tension, anxiety, depression, childhood hyperactivity, chicken pox, German measles, scarlet fever, measles, mumps, polio, rheumatic fever, malaria, mononucleosis, venereal disease, yellow jaundice, tuberculosis)?
Have you ever been turned down for life insurance, military service or employment because of health problems?
Have you ever been hospitalized for any major medical illness or operations? Have you had more than four such hospitalization? When was your most recent hospitalization? When was your first (second, third, fourth) hospitalization? What illness (operation) were you hospitalized for? What hospital were you hospitalized in? What city (state) is the hospital located?
Have you had chest x-ray (kidney x-ray, G.I series, colon x-ray, electrocardiogram, gallbladder x-ray, TB test, sigmoidoscopy, mammogram, tetanus “shots”, polio series, typhoid “shots”, flue infections, mumps “shots”, measles “shots”)?
When were you last given chest x-ray...?
Are you now taking antibiotics (penicillin, sulfa, opiates, codeine, diuretics, water pills, sedatives, stimulants, caffeine, Demedrol, blood pressure medicine, aspirin, diet pills, antacids, laxatives, cold tables)? Are you sensitive or allergic to antibiotics...?
1.Do you have any skin problems? 2.Does your skin itch or burn?
3.Do you have trouble stopping even a small cut from bleeding? 4.Do you bruise easily?
5.Do you ever faint or feel faint? 6.Is any part of your body always numb? 7.Have you ever had seizures or convulsions? 8.Has your handwriting changed lately? 9.Do you have a tendency to shake or tremble? 10.Are you very nervous around strangers? 11.Do you find it hard to make decisions? 12.Do you find it hard to concentrate or remember? 13.Do you usually feel lonely or depressed? 14.Do you often cry? 15.Would you say you have a hopeless outlook? 16.Do you have difficulty relaxing? 17.Do you have a tendency to worry a lot? 18.Are you troubled by frightening dreams or thoughts? 19.Do you have a tendency to be shy or sensitive? 20.Do you have a strong dislike for criticism? 21.Do you lose your temper often? 22.Do little things often annoy you? 23.Are you disturbed by any work or family problems? 24.Are you having any sexual difficulties? 25.Have you ever considered committing suicide? 26.Have you ever desired or sought psychiatric help?
27.Have you gained or lost more then 10 pounds in the last 6 months? 28.Do you have a tendency to be too hot or too cold? 29.Have you lost your interest in eating lately? 30.Do you always seem to be hungry? 31.Are you more thirsty than usual lately? 32.Are there any swellings in your armpits or groin? 33.Do you seem to feel exhausted or fatigued most of the time?
34.Do you have difficulty either falling asleep or staying asleep?
35.Do you exercise more than three times a week?
36.How much do you smoke per day? 37.Do you take two or more alcoholic drinks a day? 38.Do you drink more than six cups/glasses of coffee, tea or cola soda per day? 39.Are you a regular user of sleeping pills, marijuana, tranquilizers, pain killers, etc.? 40.Have you ever used heroin, cocaine, LSD, PCP, etc.?
41.Do you drive a motor vehicle more than 25,000 miles per year? 42.How often do you use seat belts when riding in cars?
43.List any country outside the United States you visited in the past six months.
44.Are you troubled by heartburn? 45.Do you feel bloated after eating? 46.Are you troubled by belching? 47.Do you suffer discomfort in the pit of your stomach? 48.Do you easily become nauseated (feel like vomiting)? 49.Have you ever vomited blood? 50.Is it difficult or painful for you to swallow? 51.Are you constipated more then twice a month? 52.Are your bowel movements ever loose for more than one day? 53.Are your bowel movements ever black or bloody? 54.Do you suffer pains when you move your bowels? 55.Have you had any bleeding from your rectum?
56.Do you frequently get up at night to urinate? 57.Do you urinate more than five or six times a day? 58.Do you wet your pants or wet your bed? 59.Have you ever had burning or pains when you urinate? 60.Has your urine ever been brown, black or bloody? 61.Do you have any difficulty starting your urine flow? 62.Do you have a constant feeling that you have to urinate?
63.Are you troubled with stiff or painful muscles or joints? 64.Are your joints ever swollen? 65.Are you troubled by pains in the back or shoulder? 66.Are your feet often painful?
67.Are you handicapped in any way? 68.Do you have headaches more than once a week? 69.Does twisting your neck quickly cause pain? 70.Have you ever had lumps or swelling in your neck?
71.Do you wear glasses? 72.Does your eyesight ever blur? 73.Is your eyesight getting worse? 74.Do ever see double? 75.Do you ever see colored halos around lights? 76.Do you ever have pains or itching in or around your eyes? 77.Do your eyes blink or water most of the time? 78.Have you had any trouble with your eyes in the last two years?
79.Do you have difficulty hearing? 80.Have you had any earaches lately? 81.Have you been troubled by running nose lately? 82.Do you have a repeated buzzing or other noises in your ears? 83.Do you get motion sickness riding in a car or plane?
84.Do you have any problems with your teeth? 85.Do you have any sore swellings on your gums or jaws? 86.Is your tongue sore or sensitive? 87.Have your taste senses changed lately?
88.Is your nose stuffed up when you don’t have a cold? 89.Does your nose run when you don’t have a cold? 90.Do you ever have sneezing spells? 91.Do you ever have head colds two or more months in a row? 92.Does your nose ever bleed for no reason at all? 93.Is your throat ever sore when you don’t have a cold? 94.Has a doctor told you that your tonsils have been enlarged? 95.Has your voice ever been hoarse when you didn’t have a cold? 96.Do you wheeze or have to gasp to breathe? 97.Are you bothered by coughing spells? 98.Do you cough up a lot of phlegm (thick spit)? 99.Have you ever coughed up blood? 100.Do you get chest colds more then once a month?
101.Are you sweating more than usual or having night sweats? 102.Have you ever been told that you had high blood pressure? 103.Have you been bothered by a thumping or racing heart? 104.Do you ever get pains or tightness in your chest? 105.Do you have trouble with dizziness or lightheadedness? 106.Does every little effort leave you short of breath? 107.Do you wake up at night of breath? 108.Are you using more pillows to help you breathe at night? 109.Do you have trouble with swollen feet or ankles? 110.Are you getting cramps in your legs at night or upon walking? 111.Have you ever been told that you have a heart murmur?
