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Health History Questionnaire:
ABOUT YOU:
Name________________________________ Today's Date______________________
Age______ Marital Status_______ DOB ___________ SSN____________________
Reason for visit?________________________________________________________
Primary Care Physician__________________________________________________
Who Referred You?______________________________________________________
Any Allergies:___________________________________________________________
Do you have any pets? __Yes or ___No Type:_________________________________
SOCIAL HISTORY:
Travel and Recreation:
___Out of this area? When & Where?__________________________________________
___Out of the USA? When & Where?___________________________________________
___Have you visited a cave? When & Where?____________________________________
Living Arrangements:
___House?
___Apartment?
___Trailor?
___Is it on or near a farm?
___Animals near or on the property? Types______________________________________
___Is there a bird roost on or near your property? ___Yes ___No
Habits:
Do you now smoke? No___, when quit?____ : Yes___ How many years?_____ # packs/day_____
Do you drink any alcohol? No__: Yes___ How much per week?__________How long____________
Do you now or have you ever used any drugs other than prescribed by a doctor? Yes____ No_____
FAMILY HISTORY:
List any medical problems on your:
mother's side of the family____________________________________________________
father's side of the family_____________________________________________________
____I am adopted
VACCINATION HISTORY:
Have you ever had these Vaccinations? Diseases?
Diptheria, pertusis, tetnus series Date_____ _____
Tetnus Booster, with or without diphtheria Date_____
Mumps, Measles, Rubella Date _____ _____
Smallpox vaccine? ____Scar present?
Polio Date_____ _____
Hepatitis B Date_____ _____
Hepatitis A Date_____ _____
Chicken Pox Date_____ _____
Yellow Fever Date_____ _____
Typhoid Date____ _____
Pneumococcus (pneumovax) Date_____ _____
MEDICAL HISTORY:
List any surgeries you have had with dates and where they were done:_____________
__________________________________________________________________
List any hospitalizations, reasons, dates, and hospital name____________________
__________________________________________________________________
Any transfusions? ___Yes ____No When?_____________
List any medical problems you have now or have had:__________________________
___________________________________________________________________
___________________________________________________________________
CURRENT MEDICATIONS; Please list:
Drug name/dosage How often taken? For what reason/symptom?
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