PATIENT HEALTH QUESTIONNAIRE

Please fill out the following form and then select SUBMIT at the bottom.

If you have ever had a listed symptom in the past, please check that symptom in the PAST column.
If you are presently having a particular symptom, check that symptom in the PRESENT column.

Correctly answering the conditions can influence treatment choices and outcome of care.

PATIENT HEALTH QUESTIONNAIRE Please fill out the following form and then select SUBMIT at the bottom. If you have ever had a listed symptom in the past, please check that symptom in the PAST column. If you are presently having a particular symptom, check that symptom in the PRESENT column. Correctly answering the conditions can influence treatment choices and outcome of care.
Abdominal pain :
Abnormal Weight Gain or Loss :
Angina :
Anorexia :
Aortic Aneurysm :
Arthritis :
Asthma :
Bladder Infection :
Blood Disorder :
Breast Soreness Lumps :
Cancer :
If yes please explain :
Chest Pains :
Chronic Cough :
Chronic Sinusitis :
Colitis :
Constipation/Irregular Bowel habits :
Convulsions :
Diabetes :
Depression :
Dermatitis/Eczema/Rash :
Difficulty in Swallowing :
Dizziness :
Emphysema :
Endometriosis :
Epilepsy :
Excessive Thirst :
Fainting :
Frequent Urination :
General Fatigue :
Hand Pain :
Right or Left? :
Headache :
Heart Attack :
If yes please list date: :
Heartburn/Indigestion :
Hepatitis :
High Blood Pressure :
Irregular Menstrual Flow :
Irritable Colon :
Jaw Pain :
Kidney Disorders (by condition) :
Kidney Stones :
Liver/Gallblader prolems :
Loss of Appetite :
Loss of Bladder Control :
Low Back Pain :
Mid Back Pain :
Muscular In-Coordination :
Neck Pain :
Pain in Ankle or Foot :
Pain in Lower Leg or Knee :
Pain in Upper Arm or Elbow :
Pain in Upper Leg or Hip :
Painful Urination :
PMS :
Profuse Menstrual Flow :
Prostate Problems :
Rapid Heart Beat :
Rheumatoid Arthritis :
Scoliosis :
Shoulder Pain :
Stroke :
Swelling, Stiffness of Joint(s) :
Tinnitus (Ear Noises) :
Tumor :
Ulcer :
Visual Disturbances :
Wrist Pain :
Other: :
HAVE YOU OR YOUR FAMILY HAD: :
Cancer :
Rheumatoid Arthritis :
Epilepsy :
Diabetes :
Chronic Back Problems :
Heart Problems :
Chronic Headaches :
High Blood Pressure :
Lung Problems :
Lupus :
Do you have a permanent disability rating? :
If yes--location? :
If yes--Date rating received? :
If yes--Rating Percentage: :
Present Weight :
Present Height :
Pregnancy: # of births-- :
Birth Control Pills: Type-- :
Medication (list if not listed elsewhere): :
Tobacco: packs per day-- :
Alcohol: # drinks per day/week/month-- :
Drug or Alcohol Dependence: If yes please explain-- :
Coffee/Tea/Caffinated Soft Drinks: # of cups/cans per day-- :
Hospitalizations/Surgical Procedures (list if not described elsewhere)-- :
I certify that the above information is complete and accurate to the best of my knowledge. I agree to notify this Doctor immediately whenever I have changes in my health condition. :
Please copy the 5 characters :
Please copy the 5 characters :