FAMILY PRACTICE HEALTH HISTORY QUESTIONNAIRE

Your answers on this form will help your health care provider better understand your medical
concerns and conditions. If you are uncomfortable with any question, do not answer it. If you
cannot remember specific details, please approximate. Add any notes you think are important.
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT
STRICTLY CONFIDENTIAL.

ALLERGIES
List anything that you are allergic to (medications, food, bee stings, etc.) and how each affects you.

ALLERGY
1. Grass

REACTION
hives, shallow breathing

2. trees

itchy eyes, stuffy/runny nose

3. cats & dogs

itchy eyes, stuffy/runny nose, hives

Art City Pharmacy

FAVORITE PHARMACY: __________________________________________________________
MEDICATIONS
Please list all the medications you are taking. Include prescribed drugs and over-the-counter drugs, i.e.,
vitamins and inhalers.

DRUG NAME
1. Zyrtec

STRENGTH
OTC

FREQUENCY TAKEN

2. Sudafed PE
3. Mucinex

10mg

q4h prn

400mg

4. Advil

200mg

q4h prn
2-4 q6-8h prn

Daily

5. Fish Oil

daily

6. calcium +D

daily

7. multi-vit
8.

daily

9.
10.

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IMMUNIZATION HISTORY
Immunizations and most recent date:

Chickenpox

Date:

Flu Shot

Date:

Gardasil/HPV

Date:

Hepatitis A

Date:

Hepatitis B

Date:

Meningococcus
x MMR (Measles, Mumps,
Rubella)
Pneumonia
Tdap (Tetanus and
pertussis)
Tetanus
Zostavax (Shingles)

(WOMEN ONLY) OBSTETRIC AND GYNECOLOGICAL HISTORY

Last PAP Smear
Date: 4/24/09 Abnormal
Last Mammogram
Date:
Abnormal
Age of First Menstrual Period 14
Last Period / Age of Menopause (Date / Age): 4/10 39
Number of pregnancies: 4
Number of Miscarriages: 1
Number of Cesarean sections: 0
Number of Births: 3
Number of Abortions: 0
x Male
Current sexual partner is:
Female

x No
Do you use condoms?
Yes

Other Birth control method used: no uterus

Interested in being screened for STDs:
Yes x No

Date: 6/15/88
Date:
Date:
Date:
Date:

CHECK BELOW IF APPLIES TO YOU:

Bleeding between periods
Heavy Periods
Extreme Menstrual Pain
Vaginal itching, burning, or
discharge
x Waking in the night to go to

the bathroom
x
Hot flashes
Breast lump or nipple
discharge
Painful intercourse
x Sexually Active

PAST MEDICAL HISTORY (Please check all that apply)

Anxiety Disorder
Diverticulitis
Arthritis
Fibromyalgia
x
Asthma
Gout
Bleeding Disorder
Has Pacemaker
Blood Clots
Heart Attack
Cancer
Heart Murmur
Coronary Artery Disease Hiatal Hernia or Reflux Disease
Claustrophobic
HIV or AIDS
Diabetes Insulin
High Cholesterol
Diabetes Non-Insulin
High Blood Pressure
Dialysis
Overactive Thyroid
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Date:

Kidney Disease
Kidney Stones
Leg/Foot Ulcers
x Liver Disease

Osteoporosis
Polio
Pulmonary Embolism
Reflux or Ulcers
Stroke
Tuberculosis
Other

PAST SURGICAL HISTORY

SURGERY
1. oblation
2. hysterectomy
3. Shoulder

REASON
polyps, heavy bleeding

YEAR HOSPITAL
2007 Union Hospital

endometriosis, bleeding

2010 AF Hospital
2012 AF Hospital

torn cartilidge

4.
5.

FAMILY HEALTH HISTORY

FATHER
MOTHER
BROTHER/SISTER
BROTHER/SISTER
OTHER:

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x
x
x

x
x

50

49

x
x

76

STROKE

OSTEOPOROSIS

GENETIC DISEASE

DIABETES

CANCER

DEPRESSION

ARTHRITIS
x

HYPERTENSION

Y
x N
Y
xN

Y
x N

Y
xN

xY

N
Y
xN

xY

N
xY

N
Y
N

HEART DISEASE

GRANDMOTHER
(MATERNAL)
GRANDFATHER
(MATERNAL)
GRANDMOTHER
(PATERNAL)
GRANDFATHER
(PATERNAL)

AGE

ALIVE?

RELATION

ALCOHOLISM

SIGNIFICANT HEALTH PROBLEMS IN MY FAMILY

x
x

SOCIAL HISTORY
EDUCATION
MARITAL STATUS
th
x Married Separated
< 8 grade

High School
2 Yr College
x 4 Yr College

Post Graduate
ALCOHOL
Drink Alcohol?

Yes

x
No

Single
Divorced

Widowed
Domestic Partner

EXERCISE

CAFFEINE

No exercise
x Occasional exercise

Moderate exercise
High level exercise

None
Occasional
x Moderate

Heavy
# cups/cans per day? ____
1-2

TOBACCO

DRUGS

Do you use Tobacco?

x
Yes No

Do you currently use recreational or

street drugs?
x If yes, please list:
Yes No

How often?

If not now, did you ever use tobacco?

x
Yes No
Cigarettes ____ pks./day

Occasionally

Chew ____ /day

< 3 times/week

Cigars ____/day

> 3 times/week

# Years Used ____

# Drinks/week? ____

Or year quit ____

ADDITIONAL HEALTH FACTS

Please add other information about your health that you would like your provider to know here:

Mirriam C Draper

PARENT, GUARDIAN OR CAREGIVER SIGNATURE

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4/1/2015

DATE