RMG Medical History Questionnaire

Last Name:
First Name:
Date of Birth:
Medical History Questionaire
Please list your major medical problems:
Please list all surgeries that you have had (include cosmetic):
Surgery:
Date:
Please list all medication you are currently taking:
Medication: Dosage: Frequency:
Please list any allergies that you have:
Medication:
Reaction:

Medical History Questionaire
Continued
Social History (circle when appropriate):
Occupation:
Marital status: Married Single Widowed
Divorced
Exercise:
Never
1-2x per week 3-4x per week
Daily
List activities:
Tobacco use:
Yes
No
Quit. If so, when?
If yes, what do you smoke and how much per day or week?
How many years did you smoke tobacco products for?
Alcohol use: Never Rarely Socially Weekly Daily
What do you drink and how often per day or week?
Illicit drug use:
Yes
No
Quit. If so, when?
If yes, or have quit, please list what you are (or were) taking.
Sexually active:
Yes
No
Sexual orientation:
Heterosexual Homosexual Bisexual
How many sexual partners do you have currently?
Any history of sexually transmitted diseases (STDs)?
Please list them.
Do you use contraception? If so, please list what you currently use.
Family History: please check box if adopted
Alive Deceased Age
Mother
Father
Brother/Sister
Brother/Sister
Brother/Sister
Other
Other
Then proceed to the next question.
Medical problems and age at diagnosis:

Medical History Questionaire
Continued
Do you have children? If yes, how many?
Please list any medical problems with your children:
Vaccines
Date
Vaccines
Date
Tetanus shot
Zostavax (shingles)
Flu shot
Gardasil (HPV)
Pneumonia shot
Meningococcal
Hepatitis A
Hepatitis B