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Home
About Us
Services
Health Professionals
- Submit a Referral
Patients
DOC Providers
Blog
Media/Press
Contact Us

Health History Form

All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.

Name:
First Middle Last
Sex:
- Male
- Female
Date of Birth:
Marital Status:
Name of Primary Doctor:
Date of Last Physical Exam:
Office Tel:
Fax:
Email:
Name of Specialist:
Office Tel:
Fax:
Email:
Personal Health History
Childhood Illness:
- Measles
- Mumps
- Rubella
- Chickenpox
- Rheumatic Fever
- Polio
Immunizations and Dates:
- Tetanus
- Pneumonia
- Hepatitis
- Chickenpox
- Influenza
- MMR Measles
- Mumps
- Rubella
List any medical problems that other doctors have diagnosed:
Surgeries
Please list the year, reason and hospital.
Other Hospitalizations:
Please list the date, reason and hospital.
Have you ever had a blood transfusion?
- Yes
- No
List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers:
Allergies to medications:
Health Habits and Personal Safety
All questions contained in this section are optional and will be keep strictly confidential.
Exercise:
Amount of exercise:
- Sedentary (No exercise)
- Mild exercise (i.e., climb stairs, walk 3 blocks, golf )
- Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
- Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Diet:
Are you dieting?
- Yes
- No
If yes, are you on a physician prescribed medical diet?
- Yes
- No
Rank salt intake:
- High
- Medium
- Low
Rank fat intake:
- High
- Medium
- Low
Caffeine:
Source of Caffeine:
- Coffee
- Tea
- Cola
- None
Number of cups / cans per day?
Alcohol:
Do you drink alcohol?
- Yes
- No
If yes, what kind?
How many drinks per day / week?
Are you concerned about the amount you drink?
- Yes
- No
Have you considered stopping?
- Yes
- No
Have you ever experienced blackouts?
- Yes
- No
Are you prone to “binge” drinking?
- Yes
- No
Do you drive after drinking?
- Yes
- No
Drugs:
Do you currently use recreational or street drugs?
- Yes
- No
Have you ever given yourself street drugs with a needle?
- Yes
- No
Sex:
Are you sexually active?
- Yes
- No
Any discomfort with intercourse?
- Yes
- No
Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?
- Yes
- No
Personal Safety:
Do you live alone?
- Yes
- No
Do you have frequent falls?
- Yes
- No
Do you have vision or hearing loss?
- Yes
- No
Do you have an Advance Directive or Living Will?
- First Choice
- Second Choice
- Third Choice
Would you like information on the preparation of these?
- Yes
- No
Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?
- Yes
- No
Family Health History
Father
Deceased
- Yes
- No
Significant Health Problems:
Mother
Deceased
- Yes
- No
Sibling
- Male
- Female
Deceased
- Yes
- No
Significant Health Problems
Sibling
- Male
- Female
Deceased
- Yes
- No
Significant Health Problems
Sibling
- Male
- Female
Deceased
- Yes
- No
Significant Health Problems
Sibling
- Male
- Female
Deceased
- Yes
- No
Significant Health Problems
Sibling
- Male
- Female
Deceased
- Yes
- No
Significant Health Problems
Child
- Male
- Female
Deceased
- Yes
- No
Significant Health Problems
Child
- Male
- Female
Deceased
- Yes
- No
Significant Health Problems
Child
- Male
- Female
Deceased
- Yes
- No
Significant Health Problems
Child
- Male
- Female
Deceased
- Yes
- No
Significant Health Problems
Grandmother - Maternal
Deceased
- Yes
- No
Significant Health Problems
Grandfather - Maternal
Deceased
- Yes
- No
Significant Health Problems
Grandmother - Paternal
Deceased
- Yes
- No
Significant Health Problems
Grandfather - Paternal
Deceased
- Yes
- No
Significant Health Problems
Mental Health
Is stress a major problem for you?
- Yes
- No
Do you feel depressed?
- Yes
- No
Do you panic when stressed?
- Yes
- No
Do you have problems with eating or your appetite?
- Yes
- No
Do you cry frequently?
- Yes
- No
Have you ever attempted suicide?
- Yes
- No
Have you ever seriously thought about hurting yourself?
- Yes
- No
Do you have trouble sleeping?
- Yes
- No
Additional Medications or Comments

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NYC Administrative Office:
6010 Bay Parkway 9th Floor
Brooklyn, NY 11204
Phone: 718-238-2100 • Fax: 718-748-0863

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Doctors On Call offers medical house calls for elderly and homebound patients throughout NY’s five boroughs, Long Island, and Lower Westchester. Our team of physicians, nurse practitioners, and physician assistants provide expert medical treatment for chronic diseases, sick visits, and post hospital care.