HEALTH HISTORY QUESTIONNAIRE

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Nigel Ernest McDowell
5 years ago
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1 L 3/11 Page 1 HEALTH HISTORY QUESTIONNAIRE NAME: DATE: HOME ADDRESS: HOME PHONE: WORK PHONE: CELL PHONE: OTHER PHONE: EMPLOYER: OCCUPATION: EXPLAIN YOUR JOB DUTIES: DATE OF BIRTH: SEX: MALE /FEMALE SS# HIGHEST LEVEL OF SCHOOL / DEGREE? COUNTRY OF BIRTH: HOW LONG HAVE YOU LIVED IN THE U.S: HAVE YOU SERVED IN THE MILITARY: NAME OF SIGNIFICANT OTHER / SPOUSE: SINGLE: MARRIED: WIDOWED: ENGAGED: OTHER: SEPARATED: DIVORCED: SIGNIFICANT OTHER / PARTNER CHILDREN NUMBER OF CHILDREN: AGES OF THE CHILDREN: YOUR WEIGHT NOW: HAVE YOU EVER BEEN OVERWEIGHT? YOUR HEIGHT: IF YES HOW MUCH DID YOU WEIGH:

2 LIVING ARRANGEMENTS: (WHO DO YOU LIVE WITH?) Page 2 LIST FAMILY MEMBERS AND/OR FRIENDS WHO CAN HELP WITH YOUR MEDICAL CARE: WHAT IS YOUR ETHNIC BACKGROUND: American Indian Chinese Puerto Rican Alaska Native Filipino Cuban African American Japanese Hispanic other African (continental) Korean European West Indian Vietnamese Arab/middle eastern Native Hawaiian Asian Other White Pacific Islander Mexican Other WHAT IS YOUR MOTHERS ETHNIC BACKGROUND: American Indian Chinese Puerto Rican Alaska Native Filipino Cuban African American Japanese Hispanic other African (continental) Korean European West Indian Vietnamese Arab/middle eastern Native Hawaiian Asian Other White Pacific Islander Mexican Other WHAT IS YOUR FATHERS ETHNIC BACKGROUND: American Indian Chinese Puerto Rican Alaska Native Filipino Cuban African American Japanese Hispanic other African (continental) Korean European West Indian Vietnamese Arab/middle eastern Native Hawaiian Asian Other White Pacific Islander Mexican Other

3 PAGE 3 NAME / ADDRESS / PHONE NUMBER OF YOUR PRIMARY CARE PHYSICIAN: NAME / ADDRESS / PHONE NUMBER OF OTHER SPECIALTY PHYSICIANS YOU SEE: DO YOU HAVE ANY ALLERGIES? IF YES, WHAT ARE YOU ALLERGIC TO: IF YES, WHAT WERE THE ALLERGY REACTIONS/SYMPTOMS: HAVE YOU HAD ANY INJURIES? IF YES, WHAT TYPE OF INJURIES HAVE YOU HAD?

4 PAGE 4 HAVE YOU EVER BEEN ADMITTED TO THE HOSPITAL? IF YES, FOR WHAT REASON? HAVE YOU HAD ANY OPERATIONS/SURGERIES? IF YES, WHAT TYPE OF OPERATIONS HAVE YOU HAD? HAVE YOU HAD ANY ABDOMINAL SURGERIES/OPERATIONS? IF YES, WHAT TYPE OF ABDOMINAL SURGERIES HAVE YOU HAD? HAVE YOU EVER HAD ANY COMPLICATIONS FROM THE SURGERIES? IF YES, WHAT TYPE OF COMPLICATIONS? HAVE YOU HAD GENERAL ANESTHESIA? HAVE YOU EVER HAD ANY COMPLICATIONS FROM THE ANESTHESIA? IF YES, WHAT TYPE OF COMPLICATIONS? DO YOU HAVE ANY MEDICAL PROBLEMS? IF YES, WHAT ARE THEY?

5 HAVE YOU HAD ANY SEVERE INFECTIONS? PAGE 5 IF YES, WHEN WERE THEY? WERE YOU HOSPITALIZED WITH THEM? WHEN WERE YOU HOSPITALIZED? DID YOU RECEIVE ANTIBIOTICS? DO YOU KNOW THE TYPE OF INFECTIONS YOU HAD? IF YES, WHAT TYPE? HAVE YOU HAD ANY BLOOD TRANSFUSIONS? IF YES, WHEN? IF YES, WHEN DID YOU HAVE THE TRANSFUSIONS: IF YES, DID YOU HAVE ANY REACTIONS TO THE BLOOD TRANSFUSIONS AND IF YES, WHAT WERE THEY: WILL YOU ACCEPT BLOOD TRANFUSIONS AS NEEDED MEDICALLY? DO YOU TAKE MEDICATIONS? IF YES: PRESCRIBED: OVER THE COUNTER: BIRTH CONTROL: HERBAL SUPPLEMENTS: OTHER:

6 REVIEW OF MEDICAL SYSTEMS: PAGE 6 1. Do you have any skin disease: If yes, what kind? 2. Do you have arthritis? 3. Do you have any back pain? 4. Do you have any headaches? 5. Do you have any loss of feeling in your arms or legs? If yes, where? 6. Do you bruise easily? 7. Have you ever had problems with bleeding? 8. Have you ever had a blood clot? If yes, where was it? How was it treated? 9. Do you have anemia? 10. Do you have high blood pressure? If you do, are you being treated for it? name of medication(s)? 11. Do you have Thyroid disease? If yes, are you being treated for it? name of medication?

7 12. Do you have a chronic cough? PAGE 7 Any wheezing? Bronchitis? Asthma? Tuberculosis? If yes, when & treatment Pneumonia? 13. Do you use an inhaler? If yes, what kind? How often? 14. Do you smoke? If you do, how much do you smoke? Did you ever smoke? When did you quit smoking? 15. Have you ever had heart disease or a heart attack? 16. Have you ever had heart surgery? If yes when? 17. Have you ever had chest pain? Do you take medications for it? If yes what kind? 18. Do you have high cholesterol? If yes, do you take medications for it? If yes, what type? 19. Do you have shortness of breath?

8 PAGE Do you use oxygen? If yes, how much? 21. How many flights of stairs can you climb easily? 22. Do your feet, ankles, or legs swell? If yes, when? 23. Do you have ascites (fluid in the abdomen)? If yes, when? Have you ever had a paracentesis? If yes, when? How much fluid was removed? 24. Do you get stomach aches / pain? If yes, when? How frequently? Is it food related? Do you take medication for it? If yes, what type? Does it provide relief? What does provide relief from the pain? 25. Have you ever been diagnosed with an intestinal disease / disorder? If yes, what type?

9 26 Do you have chronic diarrhea? PAGE 9 If yes, how often? Do you take medications for it? Does it control or stop the diarrhea? 27. Do you have bouts of constipation? If yes, how often? What provides relief? 28. Have you ever had blood in the stool? If yes, when? 29. Have you ever thrown up blood? If yes, when? Where you hospitalized? Did you need to receive blood transfusions? 30. Have you ever had stomach ulcers? If yes, when? Were you treated for it? 31. Have you ever had gallbladder trouble? 32. Do you have diabetes? If yes, do you use insulin, oral medication, or diet control? 33. Have you ever been jaundiced? 34. Have you ever been told you have hepatitis? If yes, when and what type? 35. Have you ever been told you had liver disease? If yes, what type of liver disease?

10 PAGE Do you drink beer, wine, or alcohol? If yes, how often? Do you drink socially? When was the last time? What is the amount of alcohol do you drink? 37. Did you ever drink beer, wine, or alcohol? If yes, when did you stop? If yes, how much did you drink in the past? 38. Have you ever been told to stop drinking? If yes, when? 39. Have you ever had bladder problems? 40. Have you ever had any problems with painful urination? 41. Do you urinate frequently? 42. Do you have to urinate during the night? 43. Have you ever had difficulty in urination? 44. Have you ever had kidney stones? If yes, when and did you have treatment? 45. Have you ever had an urinary tract infection? If yes, when? Did you have treatment? If yes, what kind? 46. Have you ever had a kidney infection? If yes, when and what was used for treatment?

11 47. Have you ever needed dialysis? PAGE 11 If yes, when? If you are on dialysis now, what date did you first start? If you are on dialysis now, what days do you go to dialysis? 48. Have you ever had a tumor? If yes, where was it? Was it cancer? How was it treated? 49. Have you ever had any blackout spells? 50. Have you ever had seizures? If yes, when? Are you still being treated for seizures? 51. Have you ever consulted with a psychiatrist? 52. Have you ever felt the need to see a psychiatrist? 53. Do you have any problems with anxiety? If yes, when? 54. Do you take any medications for anxiety? If yes, when? What type of medications are you taking? How do you cope during and anxiety episode?

12 PAGE Do you have any problems with depression? If yes, when? 56. Do you take medications for depression? If yes, what is the medication? How do you cope during a depressive episode? 57. Have you ever traveled out of the country? If yes, what countries did you travel to:

13 PAGE 13 QUESTIONS ONLY FOR MALES: Have you ever had a venereal disease? If yes, what type, when, and treatment? 2. Do you have any testicular swelling? 3. Have you ever had testicular cancer? If yes, when? 4. Do you have regular prostate exams? 5. Do you have prostate problems? 6. Do you have any penile discharge?

14 QUESTIONS ONLY FOR FEMALES PAGE When was your last menstrual period? 2. Are you pregnant now? 3. Do you have regular periods? 4. Do you have painful cramps? 5. Have you ever been diagnosed with endometriosis? 6. How many pregnancies have you had? 7. Have you had any complications with the pregnancies? If yes, what were they? 8. Did you have vaginal births or C-Sections? 9. Do you have frequent vaginal or yeast infections? If yes, when was the last one? If yes, what was the treatment? 10. Have you ever had a venereal disease? If yes, what type, when, and treatment? 11. Do you have regular PAP Smears and Pelvic Exams? If yes, when was your last one? If yes, what were the results? 12. Do you have regular Mammograms? If yes, when was your last one? If yes, what were the results?

15 QUESTIONS ONLY FOR FEMALES PAGE Have you ever had abnormal Mammograms? If yes, what was the abnormality? 14. Have you ever had breast cancer? If yes, when and how was it treated? 13. Do you take Hormone replacement therapy? If yes, what type?

16 Have you had any other medical problems that were not mentioned? PAGE 16 If yes, please list: _ What treatment(s) are you getting? _ How do you rank your health status at this present time? Excellent Fair Good Poor FAMILY HISTORY: What diseases are there in your family? (include parents, grandparents, brothers, sisters, children) Have you ever had: Measles: Mumps: Chickenpox: Rheumatic fever: Mononucleosis: Hepatitis A: Hepatitis B: Hepatitis C: Tuberculosis: Have you ever been immunized for the following? Hepatitis A When? Hepatitis B When?

17 PAGE 17 HAVE YOU HAD ANY OF THE FOLLOWING TESTS / PROCEDURES 1. CT-SCAN? If yes when? What part of the body did they scan? 2. MRI? If yes when? What part of the body did they scan? 3. Ultrasound? If yes when? What part of they body did they scan? 4. Chest X-Ray? If yes when? 5. Liver Biopsy? If yes when? 6. Echocardiogram? If yes when? 7. Cardiac Stress test? If yes when? 8. Cardiac Catheterization? If yes when? 9. Pulmonary Function Testing? If yes when? 10. Upper endoscopy? If yes when? 11. Colonoscopy? If yes when? 12. ERCP? If yes when? 13. TIPS (Transjugular intrahepatic portal-systemic shunt)? If yes when? 14. Other tests and when?

18 APPROVAL DATE: Chief, Director of Transplantation MD APPROVAL DATE:

Hematology Oncology Associate of Central New York Medical History

Hematology Oncology Associate of Central New York Medical History Name: Date: Male Female Age: Consult Date: Reason for today s visit: Referring Doctor: Primary Care Doctor: Surgeon & Other Doctors: Medical