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Patient History Questionnaire Form
Weekend Warrior Exercises – Well Played or Waste of Time?
February 23, 2017
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Published by
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June 27, 2017
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PATIENT HISTORY QUESTIONAIRE
TODAYS DATE
Name
First
Last
Date of Birth
Sex
Male
Female
Status
Married
Single
Widowed
Divorced
Long term relationsgim
PRIOR MEDICAL HISTORY
Illnesses Anemia
Yes
No
Diabetes
Yes
No
Tuberculosis
Yes
No
Stroke
Yes
No
Stomach Ulcer
Yes
No
Stomach Ulcer
Yes
No
Chicken Pox
Yes
No
Measles
Yes
No
Mumps
Yes
No
Arthritis
Yes
No
Rheumatic Fever
Yes
No
Cancer
Yes
No
Thyroid Condition
Yes
No
Pneumonia
Yes
No
Hepatitis
Yes
No
Kidney Disease
Yes
No
Asthma
Yes
No
Back Problems
Yes
No
Blood Transfusion
Yes
No
Migraine Headaches
Yes
No
Open Heart
Yes
No
Angioplasty
Yes
No
Stent
Yes
No
Pacemaker
Yes
No
Prostate
Yes
No
Gallbladder
Yes
No
Hernia
Yes
No
Hysterectomy
Yes
No
Appendectomy
Yes
No
Tonsillectomy
Yes
No
Other Surgeries
CARDIAC (HEART) HISTORY
Heart Attack
Yes
No
High Blood Pressure
Yes
No
Coronary Artery Disease
Yes
No
Elevated cholesterol
Yes
No
Chest Pain / discomfort
Yes
No
Heart Palpitations
Yes
No
Shortness of Breath
Yes
No
Heart Murmur
Yes
No
Mitral regurgitation
Yes
No
Other heart conditions
ALLERGIES
Penicillin
Yes
No
Penicillin
Yes
No
Sulfa
Yes
No
FAMILY HISTORY
Father alive?
Yes
No
Fathers age
Fathers Health
Father deceased at age
cause of death
Mother alive?
Yes
No
Mothers age
Mothers Health
Mother deceased at age
cause of death
Brothers
Sisters
Do you have a family history of:
Heart Attack?
Yes
No
Cancer?
Yes
No
Stroke?
Yes
No
High Blood Pressure?
Yes
No
Diabetes?
Yes
No
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