Health Check Form

Birth date

Marital Status SingleMarriedDivorcedWidowed

Smoking: (If yes, state quantity):

Alcohol: (If yes, state quantity):

Other Substances:(If yes, specify)

Date of last menstrual period:

Prescriptions/Medications:

Number of pregnancies:

Number of live births:

Last childbirth (Date):

Method of birth control: (Specify)

If menopausal, date of onset:

Drug Use:
YesNo

Drug allergies/adverse drug reaction:
YesNo

Reaction to Anaesthesia:
YesNo

Blood Transfusion:
YesNo

Sexually Transmitted Disease:
YesNo

Hepatitis:
YesNo

Breast Feeding:
YesNo

Hereditary health concerns:
YesNo

Blood Pressure:
YesNo

Cholesterol:
YesNo

Cancer:
YesNo

Kidney Disease:
YesNo

Epilepsy or Seizures:
YesNo

Anemia:
YesNo

Arthritis:
YesNo

Asthma/Emphysema:
YesNo

Gallbladder Disease:
YesNo

Cancer:
YesNo

Difficulty in Swallowing/Stroke:
YesNo

Joint Pain:
YesNo

Constipation or Diarrhea:
YesNo

Abnormal Vaginal Bleeding:
YesNo

Swollen Glands:
YesNo

Anxiety:
YesNo

Pelvic Pain:
YesNo

Reflux:
YesNo

Chest Pain:
YesNo

Shortness of Breath:
YesNo

Difficulty Sleeping/Apnea:
YesNo

Nausea:
YesNo

Dizziness:
YesNo

Rectal Bleeding:
YesNo

Burning w/Urination:
YesNo

Hot Flashes:
YesNo

Burning w/Urination:
YesNo

Murmur:
YesNo

Cardiac failure:
YesNo

Rhythm disturbances:
YesNo