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Medical History Questionnaire

Patient Name

Date of Exam

Email

Day Phone

Cell Phone

Date of Birth

Height

Weight

Date of Last Menstrual Period

Reason for Exam

Do you have Asthma?

Yes No

Are you Allergic to X-ray Dye?

Yes No

Are you Allergic to MRI Dye?

Yes No

Are you Allergic to Latex?

Yes No

Food or Drug Allergies?

Yes No

Details

Do you have Diabetes?

Yes No

Do you have Kidney Disease?

Yes No

# of alcoholic drinks per week?

Smoking History

Never Smoked Former Smoker Current Smoker

When did you quit?

How many years have you smoked?

How many packs per day do you usually smoke?

Cancer History

Do you have or have had cancer?

Yes No

Type of Cancer?

Have you had chemotherapy?

Yes No

Have you had radiation therapy?

Yes No

When was the radiation therapy?

Surgical History (please list surgeries and dates)

Appendix

Yes No

Date of Surgery

Brain

Yes No

Date of Surgery

Gallbladder

Yes No

Date of Surgery

Ovaries

Yes No

Date of Surgery

Pacemaker

Yes No

Date of Surgery

Sinus

Yes No

Date of Surgery

Spine

Yes No

Date of Surgery

Uterus

Yes No

Date of Surgery

Other

Yes No

Date of Surgery

Previous Studies

CT Scan

Yes No

When?

Where?

Mammogram

Yes No

When?

Where?

MRI Scan

Yes No

When?

Where?

Nuclear/PET Scan

Yes No

When?

Where?

Ultrasound

Yes No

When?

Where?

X-Rays

Yes No

When?

Where?

Health Conditions

Circulation (heart, high blood pressure, aneurysm, etc)

Yes No

Description

Digestive (esophagus, stomach, bowels, etc)

Yes No

Description

GYN (ovaries, uterus, etc)

Yes No

Description

Nervous System (seizure, stroke, hearing, vision, etc)

Yes No

Description

Respiratory (breathing, emphysema, lungs, etc)

Yes No

Description

Spine/Back (herniated disk, etc)

Yes No

Description

Skeletal System (joints, arthritis, etc)

Yes No

Description

Urinary (kidney, kidney stones, bladder, etc)

Yes No

Description

Other conditions/symptoms

Yes No

Description

Are you in pain?

Yes No

Rate your pain on 1-10 scale, where 10 is the worst pain

Medical History Questionnaire

Smoking History

Cancer History

Surgical History (please list surgeries and dates)

Previous Studies

Health Conditions

Current Medications (please list all) and/or Continuous Glucose Monitoring Systems