OnCall Healthcare Health History Questionnaire
When it comes to health history, the more information the better. Please complete this form with as much detail as possible.
First Name
Last Name
Date of Birth
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Seperated
Previous or Referring Provider
Date of Last Physical Exam
Personal Health History
Chickenpox
HIV
Measles
Mono
Mumps
Polio
Rubella
TB
Valley Fever
Other
None
Immunizations
Hepatitis
Influenza
MMR (Measles/Mumps/Rubella)
Pertussis
Pneumonia
Shingles
Tetanus
Other
None
Please check any medical problems you've had in the past
Anemia
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Autoimmune Disease
Blood Transfusion
Cancer
Cataracts
Chronic Lung Disease or COPD
Chronic Pain
Colon Polyps
Congestive Heart Failure
Deep Vein Thrombosis/Blood Clots
Dementia
Depression
Diabetes Mellitus
Fibromyalgia
GERD (heartburn)
GI bleed
Glaucoma
Heart Attack
Heart Disease or Pacemaker
High Cholesterol
High Blood Pressure
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Insomnia
Kidney Disease
Kidney Stones
Liver Disease
Migraine Headaches
Neuropathy
Osteoporosis/Osteopenia
Parkinson’s Disease
Pulmonary Embolism
Rheumatic Fever
Seasonal Allergies
Shingles
Sleep Apnea
Stroke or TIA
Thyroid Disease
Ulcers
Other
None
Please check any surgeries you've had
Appendectomy
Bariatric Surgery
Breast Surgery
Colonoscopy
Cosmetic Surgery
C-Section
Eye Surgery
Gall Bladder Removal
Heart Surgery
Hernia Repair
Hysterectomy
Orthopedic Surgery
Pacemaker
Spine Surgery
Thyroidectomy
Tonsillectomy
Tubal Ligation
Vasectomy
Other
None
Family Health History
Please provide as much detail as possible
Mother's Age
Mothers Significant Health Problems
Please check box if deceased
Father's Age
Father's Significant Health Problems
Please check box if deceased
How many siblings do you have?
What is the age(s) of your sibling(s)?
What is the sex(s) of your sibling(s)?
Are any of your sibling's deceased?
Yes
No
If yes, which sibling's are deceased?
Maternal Grandmother Age
Maternal Grandmother Significant Health Problems
Please check box if deceased
Maternal Grandfather Age
Maternal Grandfather Significant Health Problems
Please check box if deceased
Paternal Grandmother Age
Paternal Grandmother Significant Health Problems
Please check box if deceased
Paternal Grandfather Age
Paternal Grandfather Significant Health Problems
Please check box if deceased
Medication
List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers:
Do you take daily aspirin?
Yes
No
Do you take opioids?
Yes
No
Do you use medical marijuana?
Yes
No
Do you use contraception?
Yes
No
Please list medication allergies
Health Habits & Personal Safety
Do you use caffeine?
Coffee
Tea
Other
No
Do you drink alcohol?
Yes
No
If you drink alcohol, how many drinks per week?
Have you ever felt the need to cut down on your drinking?
Yes
No
Have people annoyed you by criticizing your drinking?
Yes
No
Have you ever felt guilty about drinking?
Yes
No
Have you ever felt you needed a drink first thing in the morning to steady your nerves?
Yes
No
Have you ever used tobacco or nicotine products?
Yes
No
Do you currently use tobacco or nicotine products?
Yes
No
If so, how many times per day?
If so, how many years?
If so, what type of tobacco?
Chew
Cigars
Cigarettes
Pipe
Vape
Other
Have you ever been pregnant?
Yes
No
Not Applicable
If so, how many pregnancies?
If so, number of live births?
Menopause?
Yes
No
Not Applicable
Submit