Name: Body Weight [lbs] Height [in]
Past Injuries
Do you have or have you ever had any of the following injuries?
Any injury not mentioned?
Have you ever been advised to restrict activity during the past 5 years?
Past Illnesses or Medical Concerns
Do you have or have you ever had any of the following conditions?
Are you experiencing any stresses, mood problems, relationship difficulties, or substance-related problems
which you would like resource or referral information on a confidential basis?
Do you occasionally use or are you currently taking any prescription or over-the-counter medications?
List name, dosage, and the reason the medication is used below.
Have you had any surgical operations in the last 10 years?
Has anyone in your immediate family developed heart disease before the age of 60?
Do any diseases run in your family?
Do you currently have a cold/cough, or have you had any in the last two weeks?
Have you ever been hospitalized? If yes, list date, length of stay, and reason on the next page.
Are you currently under a doctor’s care? If yes, list what you are being treated for on the next page.
Have you had a change in the size or color of a mole, or a sore that would not heal in the past year?
Do you have any special concerns regarding your health that you would like to discuss with the doctor?
Are you a current cigarette smoker?
A. How many packs of cigarettes do you smoke a day?
B. How long have you been smoking (years)?
Are you an ex-smoker?
A. How many years did you smoke?
B. How many packs a day?
C. When did you quit?
Have you used chewing tobacco or smoked cigars/pipe in the last 15 years?
I drink beers; ounces of hard liquor; ounces of wine per week.
When were your most recent immunizations?
Tetanus Flu Shot Pneumovax
When were you most recent health maintenance screening tests?
Cholesterol Results? PSA (Prostate) Results?
Mammogram Results?
Sigmoidoscopy Results?
Pap smear Results?
Describe any hobbies or recreational activities that have exposed you to noise, chemicals, or dust:
Please describe typical weekly exercise or physical activities including any exercise at work:
My current diet could be best characterized as (check all that apply):
