Women’s Health Center

Original Date:

Dates Revised:

Dr. David P. Gorman, M.D. Ms. Judy Murphy, ANP Ms. Claire Gardam, NP

HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

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

¨ M ¨ F

DOB:

Marital status:

¨ Single ¨ Partnered ¨ Married ¨ Separated ¨ Divorced ¨ Widowed

Previous or referring doctor:

Date of last physical exam:

PERSONAL HEALTH HISTORY

Childhood illness:

¨ Measles ¨ Mumps ¨ Rubella ¨ Chickenpox ¨ Rheumatic Fever ¨ Polio

Immunizations and dates:

¨ Tetanus

¨ Pneumonia

¨ Hepatitis

¨ Chickenpox

¨ Influenza

¨ MMR Measles, Mumps, Rubella

List any medical problems that other doctors have diagnosed

Surgeries

Year

Reason

Hospital

Other hospitalizations

Year

Reason

Hospital

Have you ever had a blood transfusion?

¨

Yes

¨

No

Please turn to next page

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Name the Drug			Strength			Frequency Taken
Allergies to medications
Name the Drug			Reaction You Had
HEALTH HABITS AND PERSONAL SAFETY
All questions contained in this questionnaire 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
	If yes, are you on a physician prescribed medical diet?							¨	Yes	¨	No
	# of meals you eat in an average day?
	Rank salt intake	¨ Hi		¨ Med	¨ Low
	Rank fat intake	¨ Hi		¨ Med	¨ Low
Caffeine	¨ None	¨ Coffee		¨ Tea	¨ Cola
	# of cups/cans per day?
Alcohol	Do you drink alcohol?							¨	Yes	¨	No
	If yes, what kind?
	How many drinks per week?
	Are you concerned about the amount you drink?							¨	Yes	¨	No
	Have you considered stopping?							¨	Yes	¨	No
	Have you ever experienced blackouts?							¨	Yes	¨	No
	Are you prone to “binge” drinking?							¨	Yes	¨	No
	Do you drive after drinking?							¨	Yes	¨	No
Tobacco	Do you use tobacco?							¨	Yes	¨	No
	¨ Cigarettes – pks./day			¨ Chew - #/day	¨ Pipe - #/day		¨ Cigars - #/day
	¨ # of years	¨ 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
Sex	Are you sexually active?							¨	Yes	¨	No
	If yes, are you trying for a pregnancy?							¨	Yes	¨	No
	If not trying for a pregnancy list contraceptive or barrier method used:
	Any discomfort with intercourse?							¨	Yes	¨	No
	Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?
								¨	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
	Do you have an Advance Directive or Living Will?