Complete Women's Care - Health History

Complete Women's Care, & Medical Spa Gynecology, Women's Health & Aesthetic Medicine 230 East Evergreen Street Sherman, Texas 75090 903-957-3409
HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Name Last, First, MI M F DOB:
Marital status:	Single Married Separated Divorced Widowed Partnered
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, umps, 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
	Number 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
	Number of cups or 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 and/or Living Will?							Yes	No
	Would you like information on the preparation of these?							Yes	No
	Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?
								Yes	No

FAMILY HEALTH HISTORY

	Age	Significant Health Problems	Children	Age	Significant Health Problems
F a t h e r				M F
M o t h e r				M F
S i b l i n g s	M F			M F
	M F			M F
	M F		Grandmother Maternal
	M F		Grandfather Maternal
	M F		Grandmother Paternal
	M F		Grandfather Paternal

MENTAL HEALTH

Is stress a major problem for you?	Yes	No
Do you feel depressed?	Yes	No
Do you panic when stressed?	Yes	No
Do you have problems with eating or your appetite?	Yes	No
Do you cry frequently?	Yes	No
Have you ever attempted suicide?	Yes	No
Have you ever seriously thought about hurting yourself?	Yes	No
Do you have trouble sleeping?	Yes	No
Have you ever been to a counselor?	Yes	No

WOMEN ONLY

Age at onset of menstruation:
Date of last menstruation:
Period every days
Heavy periods, irregularity, spotting, pain, or discharge?		Yes	No
Number of pregnancies	Number of live births
Are you pregnant or breastfeeding?		Yes	No
Have you had a D&C, hysterectomy, or Cesarean?		Yes	No
Any urinary tract, bladder, or kidney infections within the last year?		Yes	No
Any blood in your urine?		Yes	No
Any problems with control of urination?		Yes	No
Any hot flashes or sweating at night?		Yes	No
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?		Yes	No
Experienced any recent breast tenderness, lumps, or nipple discharge?		Yes	No
Date of last pap and rectal exam?

OTHER PROBLEMS

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.

Skin	Chest/Heart	Recent changes in:
Head/Neck	Back	Weight
Ears	Intestinal	Energy level
Nose	Bladder	Ability to sleep
Throat	Bowel	Other pain/discomfort
Lungs	Circulation

HEALTH HISTORY QUESTIONNAIRE

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

PERSONAL HEALTH HISTORY

Childhood illness:

Immunizations and dates:

List any medical problems that other doctors have diagnosed

Surgeries

Other hospitalizations

Have you ever had a blood transfusion? Yes No

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Allergies to medications

HEALTH HABITS AND PERSONAL SAFETY

Exercise

Diet

Caffeine

Alcohol

Tobacco

Drugs

Sex

Personal Safety

FAMILY HEALTH HISTORY

F a t h e r

M o t h e r

S i b l i n g s

MENTAL HEALTH

WOMEN ONLY

OTHER PROBLEMS

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

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