Your Health History

Review the following list and check any problems or condition that you are experiencing now or have experienced in the past. If you do not have any problems listed in the section, please check none

General Health

Good general health
Recent weight change
Loss of appetite
Fatigue
Fever/chills

Allergy

Drug allergies
Food allergies
Hay fever
None

Other Allergy

If your allergy is not listed you can place your allergy here

Ears, Nose, Mouth, Throat

Other Ears, Nose, Mouth, Throat

If you don't see your condition for Ears, Nose, Mouth, Throat listed you can place your condition here

Eyes

Blind spots
Blurred vision
Double vision
Loss of vision
Glaucoma
Injury
Pain
None

Eyes Other

If you do not see your condition for eyes listed you can place your condition here

Gastrointestinal

Blood in stools
Increasing constipation
Nausea
Painful bowel movements
Persistent diarrhea
Stomach or abdominal pain
Ulcer
Vomiting
None

Gastrointestinal Other

If you do not see your condition for Gastrointestinal listed you can place your condition here

Genitourinary

Genitourinary Other

If you do not see your condition for Genitourinary listed you can place your condition here

Heart and Lungs

Pain in chest
Heart attack
High blood pressure
High cholesterol
Irregular heart beat
None

Heart and Lungs Other

If you do not see your condition for Heart and Lungs listed you can place your condition here

Muscles/Joints/Bones

Back pain
Difficulty walking
Joint pain
Joint stiffness or swelling
Muscle pain or tenderness
Neck pain
None

Muscles/Joints/Bones Other

If you do not see your condition for Muscles/Joints/Bones listed you can place your condition here

Neurological

Neurological Other

If you do not see your condition for Neurological listed you can place your condition here

Psychiatric

Depression
Anxiety
Eating disorder
None

Psychiatric Other

If you do not see your condition for Psychiatric listed you can place your condition here

Pulmonary

Asthma
Blood in cough
Cancer
Chronic or frequent cough
Emphysema
Pneumonia
Shortness of breath
None

Pulmonary Other

If you do not see your condition for Pulmonary listed you can place your condition here

Skin

Rash or itching
Sun sensitivity
Hair loss
Color changes
None

Skin Other

If you do not see your condition for skin listed you can place your condition here

Are you

Right Handed
Left Handed
Both

Sleep

Snoring
Sleepwalking
Nightmares

Do you sleep well?

Yes
No

Do you feel rested when you wake?

Yes
No

Do you fall asleep during the day?

Yes
No

Patient Health History

Patient Health History

Your Information

Family History

Father

Mother

Paternal Grandmother

Paternal Grandfather

Maternal Grandmother

Maternal Grandfather

Son

Daughter

Your Health History