HEALTH HISTORY UPDATE QUESTIONNAIRE
All information contained in this questionnaire is strictly confidential and will become a part of your medical record.
Name:
Sex:
Male
Female
Date of Birth:
Age:
What is the main reason for your visit today?
Is it related to an accident?
No
Yes, it is
Work Injury
Motor vehicle accident
Other:
Are you currently in pain?
No; skip to the next question
Yes; answer the questions below
1. Where is your pain located?
2. When did the pain start?
3.
How often to do you experience pain?
Daily
Constantly
Daily/ Intermittently
Other:
4. How long does the pain last?
5. Is the pain:
Mild
Severe
Distressing
Unbearable
6. Rate your pain on a scale of 1-10 (1 being no pain and 10 being the worst pain possible).
ALLERGIES:
Since your last visit, have you developed any new allergies or had a bad reaction to a medication or food?
No
Yes; please describe below
OTHER PROVIDERS:
Since your last visit have you seen a specialist?
No
Yes; please list below.
Name of Provider
Why you were seen?
When were you seen?
Name of Provider
Why you were seen?
When were you seen?
Name of Provider
Why you were seen?
When were you seen?
IMMUNIZATIONS:
Since your last visit, have you had any vaccinations?
Please enter the year of any vaccinations you have had.
No
Yes; please indicate below and when you received it.
Hepatitis A
Flu Shot
Meningitis
MMR
Hepatitis B
Pneumonia
Shingles
Tetanus
HPV
Chicken Pox (shot or illness)
Other
HOSPITALIZATIONS/SURGERIES:
Since your last visit, have you been admitted to the hospital or had surgery?
Year
Reason for surgery/hospitalization
Hospital
Year
Reason for surgery/hospitalization
Hospital
Year
Reason for surgery/hospitalization
Hospital
MEDICAL TESTS:
Since your last visit, have you had any of the following tests performed?
No
Yes; please indicate when and where below.
Mammogram
Pap Smear
ECG/EKG
Blood work
DEXA scan
MRI
CT scan
X-rays
Vision exam
Colonoscopy/sigmoidoscopy
Other:
Thank you for taking the time to complete this form.
Signature of Patient or Legal Representative
NB-123
Created 10/22/2018 Revised 2/26/19