Please fill out the Health Questionnaire, below, online, and return via email to The Agnew Clinic at: email@example.com .
Alternatively, Please print and fill out , and FAX to 805-963-5853 or bring with you to your visit to the Agnew Clinic.
Phone: City: State: Country: Zip:
Email: Age: Marital Status:
CHIEF SYMPTOM OR MEDICAL PROBLEM AT THIS TIME:
Name of Doctor who referred you:
Please answer YES or NO to the following questions:
NEUROLOGICAL: Have you had:
Frequent or severe headaches? Clumsiness, in-coordination?
Fainting, loss of consciousness? Convulsion/epilepsy?
Dizziness? Weakness? Numbness? Depression?
Has there been a change in your vision recently? Do you wear glasses?
Do you have glaucoma/cataracts? Last eye exam:
Are you hard of hearing? Do you have ringing in your ears?
Have you had an infected or running ear?
NOSE AND THROAT:
Have you had sinus trouble? Do you have hay fever?
Have you had hoarseness or change in voice? Trouble swallowing?
Last dental exam:
Have you had any thyroid trouble? Swollen glands in neck?
History of radiation therapy to face or neck?
When was your last chest x-ray? Normal?
Have you had asthma? Do you have frequent cough?
Do you cough up any mucus or pus? Have you ever coughed up blood?
Do you smoke? How many cigarettes/day:
Date of last electrocardiogram? Normal?
History of heart disease, high blood pressure, increase in cholesterol?
Do you have chest pain or discomfort? Do you have difficulty breathing?
How many pillows do you sleep on? Do you have swollen ankles?
Are you bothered by thumping/palpitations of the heart?
Have you ever had a heart problem or heart attack?
Have you ever been told you have a heart murmur?
What is the most you have ever weighed?
Have you lost or gained weight recently? Do you have any loss of appetite?
Have you had ulcers or gall bladder disease?
Have you been troubled with nausea or vomiting?
Have you ever had jaundice (yellow eyes/skin)? Do you have abdominal pain?
Do you have heartburn or regurgitation? Have you had black or bloody stool?
Do you have frequent loose bowel(s)? Do you have constipation?
Do you use laxatives? Do you have hemorrhoids or other rectal problems?
When were your last intestinal x-rays/colonoscopy taken?
How many times do you urinate in the daytime?
How many times do you get up to urinate at night?
Have you had burning pain while urinating? Have you ever passed blood in the urine?
Has there ever been pus in the urine? Kidney/bladder infections? Stones?
Do you have trouble starting or stopping urine? Loss of control of bladder?
Have you ever had venereal disease? Any sexual problem?
Is there a history of prostate trouble?
GYNECOLOGICAL (for women only):
Have you ever had pain or lumps in your breasts? Are your menstrual periods regular?
Are your periods regular? Are you tense and nervous before periods?
Do you ever had bloody spotting between periods? Vaginal discharge?
Have your menstrual periods stopped? Have you had hot flashes?
Date of your last menstrual period: Date of last PAP smear:
Number of pregnancies: Weight of heaviest baby:
Are you on estrogen or other hormone replacement therapy?
BONES AND JOINTS:
Are your joints ever painful or swollen? Do you get muscle cramps?
Do you have severe neck or back pain? History of arthritis?
Have you had skin rash or itching? Lumps, growths, changing moles?
Have you had hives, eczema or other allergic reactions to foods or drugs?
Have you been exposed to irritating or toxic substances at work or elsewhere?
Do you usually have difficulty falling asleep? Staying asleep? Avg. hours sleep:
Do you often get spells of complete exhaustion? Are you frequently ill?
Fever, chills or night sweats recently? Chronic disease?
Did you ever have varicose veins in your legs?
Are you considered a nervous person? Does nervousness run in family?
Have you been treated for an emotional illness?
What form of exercise do you get?
How many cups of coffee or tea do you drink daily? How many alcoholic drinks?
Please list MEDICATIONS being taken (include aspirin, vitamins, birth control pills, etc). and dosage: (if you are coming into the office, please bring medicines along)
Date of last immunizations for: Tetanus: Pneumonia: Flu:
List any fractures, serious injuries or unconscious spells/concussions, and approximate dates.
Are you receiving compensation for an injury, or is litigation pending?
Are you on disability? From what are you disabled?
List operations and dates:
PAST MEDICAL HISTORY: Have you ever had:
Valley Fever Diabetes Scarlet Fever Anemia
Cancer Bleeding tendency Pneumonia
Tuberculosis Rheumatic Fever Radiation/x-ray Treatments
Other serious illness:
Is your father living? Age: Died at age: Cause:
Is your mother living? Age: Died at age: Cause:
Number of brothers living: Number of brothers deceased: Cause:
Number of sisters living: Number of sisters deceased: Cause:
Age of spouse (if living): Is spouse in good health?
Number of children: Ages:
Has anyone related to you had: Diabetes Cancer Heart disease
High blood pressure Tuberculosis Glaucoma/cataracts
Migraine headaches Does anything else run in your family?
Birthdate and birthplace:
How long have you lived in the city where you currently reside?
Have you ever lived in another country? Where?
Have you ever been in the military service? Where?
Date last worked: Highest grade of school completed:
Are there personal problems you would like to discuss?