IMIZ01 Health Questionnaire

HEALTH QUESTIONNAIRE

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Patient Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Please indicate which Chronic Medical Problems you have, if any, by checking the appropriate box and entering the year it started.

Rows	Check all that apply	Year Started
High Blood Pressure
Heart Disease
Diabetes
Stroke
Cancer
Thyroid Problems
Asthma
Emphysema/Lung Disease
Kidney Problems
Anemia
High Cholesterol
Glaucoma
Memory Loss
Ulcerative Colitis
Crohn's Disease
Liver Problems

Other Chronic Medical Problems Not listed Above and the year they started

Please List all Medications that you are currently taking, strength (in milligrams) and how often. Include non-prescription medications, vitamins and herbal supplements.

Rows	Medication	Strength (in mg)	Frequency
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

YesNo

If yes, please list them and the reaction that occurs when taken and start date.

Rows	Allergic to	Reaction	Start Date
1.
2.
3.
4.
6.
7.
8.
9.
10.
11.
12.

Social History

YesNo

Packs per day

Number of years

Year quit

YesNo

Drinks per week

YesNo

Cups per day

YesNo

What kind?

YesNo

Type

Times per week

How many cups of water per day?

SingleMarriedDivorcedWidowed

YesNo

How many?

RetiredUnemployedEmployed -number of years

YesNo

Family History

Please check if any of your family members have had any of the following medical problems:

Rows	Check all that apply
Heart Disease
Diabetes
Thyroid Issues
Stroke
High Blood Pressure
High Cholesterol
Asthma
Emphysema/Lung Disease
Cancer
Glaucoma
Mental Health
Memory Loss

Other medical problems family members have had not listed above, please list here:

Surgeries/Hospitalizations

Please list surgeries and hospitalizations, including the year:

Immunizations

Please check which immunizations you have had and the last year taken

Rows	Check all that apply	Last year taken
Tetanus Shot
Flu Shot
Pneumonia Vaccine

Other immunizations not listed above, please list here, including last year taken:

MaleFemale

Women Only

Date of last menstrual period

Contraception Type

Number of Pregnancies

Number of Live Births

Number of Miscarriages

Number of Abortions

Date of last PAP Smear

YesNo

Date of last Mammogram

YesNo

Date of last Osteoporosis Scan

YesNo

Men Only

Date of last Prostate Exam

YesNo

Date of last PSA (Prostate Blood Test)

YesNo

Procedures

Please check all procedures you have had and list the year

Rows	Check all that apply	Year
Sigmoidoscopy
Colonoscopy
EGD
EKG
Stress Test

Other procedures not listed above and year

YesNo

If yes, whom and for what reason?

Review of Symptoms

General - Please check any symptoms that you are currently having:

Rows	Check all that apply
Fever
Night Sweats
Unexplained weight loss or gain
Fatigue

Skin - Please check any symptoms that you are currently having:

Rows	Check all that apply
Rashes
Cancers
Change in hair, skin or nails

Eyes - Please check any symptoms that you are currently having:

Rows	Check all that apply
Glasses
Contact Lenses
Pain
Changing Vision
Discharge
Glaucoma

Ears/Nose/Throat - Please check any symptoms that you are currently having:

Rows	Check all that apply
Ear Pain
Change in Hearing
Persistent runny nose
Sore throat
Change in voice
Sinus Trouble

Heart - Please check any symptoms that you are currently having:

Rows	Check all that apply
Chest Pain
Swelling in ankles
Palpitations
Heart Murmur

Lungs - Please check any symptoms that you are currently having:

Rows	Check all that apply
Cough
Shortness of Breath
Wheezing

Gastrointestinal - Please check any symptoms that you are currently having:

Rows	Check all that apply
Nausea
Blood in Stool
Constipation
Ulcers
Heartburn
Diarrhea
Abdominal Pain

Genitourinary - Please check any symptoms that you are currently having:

Rows	Check all that apply
Blood in Urine
Painful or frequent urination
Incontinence
Sexually Transmitted Disease

Genitourinary - WOMEN - Please check any symptoms that you are currently having:

Rows	Check all that apply
Vaginal Discharge
Change in menstrual Cycle or Sexual Function

Genitourinary - MEN - Please check any symptoms that you are currently having:

Rows	Check all that apply
Testicular Pain
Decreased Urinary Stream
Penile Discharge
Change in Sexual Function

Orthopedic - Please check any symptoms that you are currently having:

Rows	Check all that apply
Painful joints
Muscular weakness
Swelling of Joints

Neuro - Please check any symptoms that you are currently having:

Rows	Check all that apply
Seizures
Tremor
Paralysis
Headaches
Stroke

Psych - Please check any symptoms that you are currently having:

Rows	Check all that apply
Depression
Anxiety
Agitation

Allergy - Please check any symptoms that you are currently having:

Rows	Check all that apply
Hives
Hay Fever

Circulation - Please check any symptoms that you are currently having:

Rows	Check all that apply
Leg swelling
Blood Clots

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient Signature*

Date

Clinician Signature

Date