Demographics and Health History
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Health History Questionnaire
Please Check all answers that apply and yes or no to all questions:
1. Any problems with head/headaches/trauma?
Checkbox Description
Yes
No
2. Any changes in vision/drainage/trouble seeing?
Checkbox Description
Yes
No
3. Any problems with drainage/difficulty breathing/deviated septum/polyps in nose?
Checkbox Description
Yes
No
4. Sore throat/difficulty swallowing/snoring/bad teeth/bleeding gums?
Checkbox Description
Yes
No
5. Difficulty hearing /pain in ear/ringing/drainage from ears?
Checkbox Description
Yes
No
6. Pain in neck/ numbness/ tingling in hands?
Checkbox Description
Yes
No
7. Chest pain/ feeling heart racing/heart disease?
Checkbox Description
Yes
No
8.Shortness of breath/coughing/dark colored sputum?
Checkbox Description
Yes
No
9.Indigestion/nausea/vomiting/dark colored stools/ diarrhea/constipation
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Yes
No
10.Difficulty holding urine/burning/blood in urine/discharge/increased in urination?
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Yes
no
11. Regular periods/discharge/burning/itching?
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Yes
No
12.Pain /swelling/redness in joints?
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Yes
No
13.Numbness/tingling/burning of legs/feet?
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Yes
No
14. Itching/dryness/flaking/rashes/sores or skin disorders?
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Yes
No
15. Any bleeding disorders/history of blood clots?
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Yes
No
16. Difficulty with hot/cold tolerance?
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Yes
No
17. Sore breast exams?
Checkbox Description
Yes
No
18. Perform self breast exams?
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Yes
No
19. Changes in weight /fatigue/weakness/fever/chills/night sweats?
Checkbox Description
Yes
No
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