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MEDICALHEALTHHISTORYQUESTIONNAIREName______________________________________________________________________________Address ______________________________________________________________________________Contact phone numbers ______________________________________________________________Birth date_____________________________________________________________________________Family Physician and/or Primary Health Care Provider:Doctor/Other________________________________Phone _________________________________Address _____________________________________City ____________________________________May I send a copy of your consultation to your physician or primary health careprovider and consult with them as necessary?YesNoSignature:_____________________________________________________________________________Marital Status:SingleMarriedDivorcedWidowedSex:MaleFemaleEducation:GradeSchoolJr. High SchoolHigh SchoolCollege (2-4 years)Graduate SchoolDegree_______________Occupation:Position _____________________________________Employer ______________________________Address ______________________________________________________________________________Phone______________________________________________________________________________Present Medical HistoryCheck those questions to which you answer yes (leave the others blank).Has a doctor ever said your blood pressure was too high?Do you ever have pain in your chest or heart?Are you often bothered by a thumping of the heart?Does your heart often race?
Do you ever notice extra heartbeats or skipped beats?Are your ankles often badly swollen?Do cold hands or feet trouble you even in hot weather?Has a doctor ever said that you have or have had heart trouble, an abnormalelectrocardiogram (ECG or EKG), heart attack or coronary?Do you suffer from frequent cramps in your legs?Do you often have difficulty breathing?Do you get out of breath long before anyone else?Do you sometimes get out of breath when sitting still or sleeping?Has a doctor ever told you your cholesterol level was high?Has a doctor ever told you that you have an abdominal aorticaneurysm?Has a doctor ever told you that you have critical aortic stenosis?Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you now have or have you recently experienced:Chronic, recurrent or morning cough?Episode of coughing up blood?Increased anxiety or depression?Problems with recurrent fatigue, trouble sleeping or increased irritability?Migraine or recurrent headaches?