Health History

Please answer the following questions about your previous health as best you can and bring to your appointment.   Your health care provider will review this with you and help you complete it if necessary.

MAJOR ILLNESSES (such as diabetes, high blood pressure, heart disease, asthma, HIV infection)

SERIOUS INJURIES (broken bones, concussions etc)

OPERATIONS (include month and year)

HOSPITALIZATIONS (reason, month and year.   Omit pregnancies)

ALLERGIES (medicines, foods etc)

MEDICINES you regularly or frequently take (prescription and non-prescription).   Include dose and how often you take them.

Do you smoke cigarettes, pipe, cigars, or chew tobacco?

If so, how much?

For how many years?

If you have already quit, congratulations!   But please answer the previous two questions about the amount and add the month and year you quit:

How much alcohol do you use?

Recreational drugs?

Have you had all of your childhood immunizations?

Date of last tetanus shot?

Date of last TB skin test?                 Positive or negative?

NAME                                                                                                DATE