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MEDICAL HISTORY/SCREEN
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Height
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Feet,inches
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What is your Occupation?
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Do you work shift work?
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Do you have a doctor?
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Are you pregnant?
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Past Health History
• • •
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Other Medical Conditions
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Please list previous surgeries.
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SEXUAL HEALTH
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Have you ever been tested for HIV or AIDS?
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If yes, date?
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If sexually active, methods of STD prevention or birth control?
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Weight and diet habits
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Weight
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Were you overweight as a child
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How do you feel when you eat?
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After eating you feel
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Do you ever skip meals?
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Reasons to skip meals or overeat
• • •
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Where do you eat your meals?
• • •
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How often do you dine out?
• • •
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You feel your appetite is
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What diets have you tried?
• • •
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EXERCISE
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Do you exercise?
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What kind of exercise do you do?
• • •
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How often do you exercise?
• • •
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Other Physical Activities
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SUBSTANCES
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Do you use tobacco products?
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If yes, what kind and how much?
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Do you drink alcohol?
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If yes, what kind and how much?
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Number of days without substance use?
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Last drugs/alcohol used?
• • •
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How much?
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How long ago?
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Do you use nicotine?
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How long ago?
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Anything special we need to know
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FAMILY MEDICAL HISTORY (parents and siblings)
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Family Medical History (parents)
• • •
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Family Medical History (siblings)
• • •
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Living Parents
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Name, age
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Name, age
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Name,age
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Name,age
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Living Siblings
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Name,age
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Name,age
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Name,age
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Name,age
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Name,age
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Name,age
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Name,age
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Name,age
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Deceased Parents
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Name of Parent
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Age, Cause of death
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Name of Parent?
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Age, Cause of death
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Name of parent?
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Age, Cause of death
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Name of parent?
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Age, Cause of death
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Deceased Siblings
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Name of Sibling?
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Age, Cause of death
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Name of Sibling?
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Age, Cause of death
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Name of Sibling?
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Age, Cause of death
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Name of Sibling?
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Age, Cause of death
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