Health Questionnaire - Sharma Holistic Medical Center

Patient's Name   Reasons For Visit


Family History Other
Father                                          
Mother                                          
Siblings                                          
Mother's Relatives                                          
Father's Relatives                                          
HOSPITAL ADMISSIONS: Do not include normal pregnancies.
Year Illness or operation










MEDICAL HISTORY
Medications Name Strength How Often
List all meds including over the counter.











Drug/food allergies
Main Problems 1) 2) 3)
In the boxes below, if just a condition is specified, enter the age at which you had the condition OR enter ""C"" if you currently have the condition.
Eyes
Glaucoma
Failing vision
Cataracts
Eye pain
Double or blurred vision
Eye infections - frequent
Itching eyes
See halos
Ears
Decreased hearing
Ringing in ears
Ear infections - frequent
Dizzy spells
Nose-Throat-Mouth
Nose bleeds
Sinusitis
Frequent colds
Sore throats - frequent
Hoarseness - prolonged
Enlarged tonsils
Loss of smell
Running nose
Hay fever/Allergies
Dental problems
Bleeding gums
Jaw pain
Sore tongue
Taste changes
Respiratory
Pneumonia/Pleurisy
Bronchitis/Chronic Cough
Cough w/phlegm or blood
Asthma/Wheezing
Fever
Cardiovascular
Shortness of breath
On Exertion
Lying Flat
Chest pain (angina)
High blood pressure
Heart murmur
Palpitations
Irregular pulse
Fainting spells
Swollen ankles
Hardening of arteries
CHF
Leg pain when walking
Varicose veins
Phlebitis
Digestive
Loss of appetite - recent
Difficulty swallowing
Indigestion/Heartburn
Persistent nausea/vomiting
Peptic ulcers
Abdominal pain - chronic
Change in bowel habits
Bowel movements/day
Diarrhea
Constipation
Diverticulitis
Blood in stool
Hemorrhoids
Hernia
Ulcerative colitis
Fissures/Fistula
Vomiting of blood
Colon cancer
Urinary
Urine infections - frequent
Painful urination
Blood in urine
Prostate problems
Control of urinations
Decreased force in urination
Kidney stones
Muscular
Arthritis/Rheumatism
Gout
TMJ
Back pain - recent
Bone fracture
Joint injury/pain
Foot pain
Sciatica
Loss of limb
Sexual
Venereal disease
Sexually transmitted disease
Herpes
Chlamydia
Skin
Rashes
Hives
Acne
Psoriasis
Eczema
Lumps
Recent hair loss
Skin cancer
Endocrine
Weight loss - recent
Weight gain - recent
Anemia
Bruise easily
Cold hands & feet
Diabetes
Hypoglycemia
Thyroid Disease
Cancer
Chronic fatigue - Adrenal fatigue
Gall bladder
Jaundice
Hepatitis
Neurological
Convulsions/Seizures
Stroke
Tremors/Hand shaking
Numbness/Tingling sensations
Headaches - frequent
Mood
Sleeping difficulty
Hours of sleep per night
Nervousness
Depression
Emotional problems
Mental illness
Memory loss
Moodiness
Lack of concentration
Mood swings
Phobias
Anxiety
Viral
Chicken pox
Polio
Mumps
Measles
German measles
Rheumatic fever
Scarlet fever
Tuberculosis
Exposure heavy metals/chemicals
Do you have a living will?
Blood type
Sexually active
Low libido
Method of contraception

Ounces alcohol per week
Years smoking
Cigarettes per day
Cups coffee/tea per day
Cups of soda per day
Female Menstrual History
Age of onset
Regular
Irregular Days of flow
Length of cycle
menstruation pain/cramps
Nunmber of pregnancies
Number of live births
Number of miscarriages
Last Pap
Are you pregnant
Last Mammogram
Flushing/Menopause
Breast pain
Vaginal discharge
Sexual abuse
HRT
PMS
Tenderness in breast
Endometriosis
Fibroids
Cysts
Immunizations
Year of Last Injection
Pneumonia
Flu
Tetanus
Diptheria
Measles
Mumps
Rubella
Polio
Hepatitis