health history questionnaire · 1.do you snore? yes no don’t know in which position do you snore?...
TRANSCRIPT
HEALTH HISTORY QUESTIONNAIRE
Name: _________________________________________ D. O. B.: ____________ Date: _______________
Primary Care Physician: ____________________________ Referring Physician: ______________________
Pharmacy Name and Address: ______________________________________________________________
Medical Equipment Company (oxygen, nebulizer, CPAP, BiPAP): __________________________________
Reason for Visit: ________________________________________________________________________
Review of Systems: Check all symptoms you’ve had in the past six months:
General: HEENT Cont: Gastrointestinal: Psychiatric: □ Abdominal Pain□ Heartburn□ Nausea□ Vomiting
□ Depression□ Memory Loss□ Nervousness------------------------------------------Endocrine:---------------------------
Musculoskeletal:
□ Appetite Loss□ Daytime Sleepiness□ Fatigue□ Fever□ Night Sweats□ Trouble Sleeping□ Significant Weight Gain□ Significant Weight Loss□ Unable to Sleep Lying Flat
□ Back Pain□ Joint Pain□ Muscle Pain
□ Excessive Thirst□ Excessive Urination at Night□ Thyroid Problems------------------------------------------
Hematology: ------------------------------------- Skin:
---------------------------
□ Seasonal Allergies□ Snoring□ Sore Throat□ Visual Loss-----------------------------------Respiratory:□ Cough□ Coughing up Blood□ Shortness of Breath□ Sputum Production□ Wake up Short of Breath Neurological:
□ Itching□ Rash
□ Wheezing-----------------------------------
------------------------------------- Cardiovascular: HEENT:
□ Dizziness□ Headaches□ Numbness□ Seizures□ Stroke
□ Glaucoma□ Hoarseness□ Nasal
Congestion□ Runny Nose
□ Abnormal Blood Pressure□ Chest Pain □ Heart Failure□ Palpitations□ Swelling of Extremities
□ Abnormal Bleeding□ Anemia□ Easy Bruising------------------------------------------Genitourinary:□ Menstrual Irregularities□ Prostate Problems□ Urinary Frequency□ Urinary Urgency
Past Medical Conditions:__________________________________________________________
SocialHave you ever smoked?
How many years have you smoked?
If quit, when?
How many packs a day?
Lived with someone who smokes?
Exposure to second hand smoke?
Exposure to toxic chemicals or substances?
Alcohol use:
If you used to drink, when did you stop?
What do you drink?
No. of times per week?
□ yes □ no
_________
_________
_________
□ yes □ no
□ yes □ no
□ yes □ no
□ yes □ no
_______________
________________________________________
_________
□ yes □ no
□ Medicine □ Coffee □ Tea □ Soda □ Foods
_________□ yes □ no
_____________________
_______________________________________
□ Single □ Married □ Separated □ Widowed □ Divorced
□ yes □ no
□ yes □ no
Marijuana or hard drugs use:
Caffeine use:
Amount per day?
Within 2 hrs of sleep?:
How many hours do you sleep a night?
Occupation (if retired, past occupation):
Marital Status:
Pets:
Do you exercise?
Past Surgical: Date: _____________________________
Type of Operation:____________________________________ ________________________________________________ ________________________________________________
Allergies: List your allergies (medications, chemicals, food, etc.)
____________________________________________________________________________________________________________________________________________________Medications: List your current prescription and non-prescription drugs or attach a list if more room is needed. Name Dosage Times per Day
_____________ _______________ _____________ _______________ _____________ _______________
________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________
_______________________________________
_____________________________________________
Travel: Date and place outside of the country in the last two years:_____________________________________
_____________________________________________________________________________________________
TB skin test: When? __________Health Maintenance
Flu shot: When? __________ Pneumovax: When? __________ Results: □ positive □ negative
Pregnancy: Are you currently pregnant? □ yes □ no
Other Past Medical History: __________________________________________________
Father Mother Brother Sister Son Daughter Asthma □ □ □ □ □ □ Stroke □ □ □ □ □ □ Diabetes □ □ □ □ □ □ Emphysema □ □ □ □ □ □ Heart Disease □ □ □ □ □ □ High Blood Pressure □ □ □ □ □ □ Insomnia □ □ □ □ □ □ Kidney Disease □ □ □ □ □ □ Narcolepsy □ □ □ □ □ □ Pulmonary Fibrosis □ □ □ □ □ □ Restless Legs Syndrome □ □ □ □ □ □ Seizure Disorder □ □ □ □ □ □ Sleep Apnea □ □ □ □ □ □ Thyroid Problems □ □ □ □ □ □ Lung Cancer □ □ □ □ □ □ Other Cancer □ □ □ □ □ □
Family History
Most Recent Tests: Date Location
Chest X-Ray: __________ ____________________________________
CT Scan ______________ ____________________________________________________
Ultrasound: ______________ ____________________________________________________
MRI: ______________ ____________________________________________________
Breathing Test: ______________ ____________________________________________________
Sleep Test: ______________ ____________________________________________________
Lab Work: ______________ ____________________________________________________
1. Do you snore? □ Yes □ No □ Don’t knowIn which position do you snore? Is it worse on your back? Do you snore if you fall asleep in a chair? Does your snoring disturb anyone? Has anyone ever noticed if you stop breathing in your sleep? Do you gasp or choke while you sleep? Does anyone sleep in your bedroom with you?
□ Back only □ All positions□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No
2. Do you suffer from either of the following in the morning?
3. Do you feel sleepy during the daytime?
□ Dry mouth □ Headache
□ Yes □ No □ Don’t know
How many days per week? ______What age did it start? ______ Is it worsening? □ Yes □ No □ Don’t know
□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know
4. Have you ever had a car accident due to sleepiness?5. Do you suffer from memory problems?6. Do you ever “zone out”?7. Are you more irritable lately?8. Do you take any daytime naps?
Sleep History
How many per week? ______________ How long do you nap? _____________ Are your naps refreshing? □ Yes □ No
9. Rate the severity of your sleepiness (1 = no sleepiness and 10 = very severe sleepiness): _______
□ Yes □ No
□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know
12. Have you ever felt paralyzed when waking up or falling asleep?
13. Do you ever dream while you are falling asleep or napping?14. Do you walk or talk in your sleep?15. Do you ever accidentally urinate in bed?16. Do you have nightmares?17. Have you ever injured yourself or others while asleep?
18. What is your bedtime? _____________
11. Have you ever felt a sudden loss of strength while experiencing a strong emotion (ie. fear, surprise, laughter)?□ Yes □ No
10. Do you ever have restlessness or discomfort in your legs? □ Yes □ No
When? _____________________ What do you do to relieve it? __________________How often does it occur? ___________________ Does it interfere with your sleep? □ Do you move or kick your legs while sleeping? □
Yes □ No
Yes □ No □ Don’t know
How long does it take you to fall asleep? ________________When do you wake up? _____________________Do you wake up during the night? □ Yes □ No □ Don’t know
How many times per night? ________ What awakens you? _________________________
19. Work hours (if applicable): ____________________If you do not work, how do you occupy your days? _________________________________What do you do in the evenings? ____________________________________________
20. How likely are you to doze off or fall asleep in the following situations?
0 = Would NEVER doze 1= SLIGHT chance of dozing 2 = MODERATE chance of dozing 3 = HIGH chance of dozing
Situation Chance of Dozing
Sitting and reading 0 1 2 3
Watching TV 0 1 2 3
Sitting, inactive in a public place (e.g. a theater or a meeting) 0 1 2 3
As a passenger in a car for an hour, without a break 0 1 2 3
Lying down to rest in the afternoon, when circumstance permit 0 1 2 3
Sitting and talking to someone 0 1 2 3
Sitting quietly after a lunch without having had any alcohol 0 1 2 3
In a car, while stopped for a few minutes in traffic 0 1 2 3
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