Medical History Form/Questions

You can make the form nicer, but here a bunch of questions I would ask. HEENT: Eyes problems? If yes, explain. If yes, do you wear glasses? Hearing problems? If yes, explain. If yes, do you wear hearing aids? Sinus problems? Ears, nose or throat problems? Skin: Jaundice (yellow skin)? Eczema? Other dermatologic concerns? Neck: Any thyroid problems? Chest: Wheezing/asthma/bronchitis? If so, how severe? Abdomen: Gallbladder problems? Intestinal problems? (diverticulitis, ulcers, Barrett's) Liver problems? (cirrhosis, hepatitis) Pelvis: Age of menarche (menstrual period)? Bladder/kidney problems? GYN issues? Fertility issues? Neurologic: Mental health history? (depression, hyperactivitiy, bipolar, suicide attempts, manic depressive, schizophrenia) Addiction? Drugs (ask type), alcohol, drugs (ask type)/alcohol Epilepsy/seizures? Stroke? Orthopedic (bone) problems? Neuromuscular: Any neuromuscular problems? Cardiovascular: Heart problems/issues? High cholesterol/triglycerides? High blood pressure? Hematologic: Anemia? Any blood disorders? Sickle cell? Blood type if known? Any known history of HIV/AIDS, hepatitis B or C (most common)...you can ask, but they may or may not answer honestly Diabetes? If yes, age of onset? Cancer? If yes, type? Any other health history you would like to disclose? Pertinent surgeries? Allergies to food? Allergies to medications? Allergies to insects/environment? Then I would type it all again and ask the same questions of family history.