Health History Form

Patient Health History Form

Personal Information

Patient Name *

Patient Date of Birth *

Medication Allergies *

Food Allergies *

Current Medications *

Preferred Pharmacy *

Patient's Medical History

Anemia *

Yes
No

Depression *

Yes
No

Irritable Bowel Syndrome *

Yes
No

Anxiety *

Yes
No

Diabetes Mellitus *

Yes
No

Seizures *

Yes
No

Arthritis *

Yes
No

Food Intolerance *

Yes
No

Swallowing Problems *

Yes
No

Asthma *

Yes
No

Genetic Disorder *

Yes
No

Thyroid Disease *

Yes
No

Bleeding Disorder *

Yes
No

GERD (acid reflux) *

Yes
No

UTI *

Yes
No

Celiac Disease *

Yes
No

Heart Disease *

Yes
No

Constipation *

Yes
No

Inflammatory Bowel Disease *

Yes
No

Additional Medical History

Surgical History

Adenoidectomy *

Yes
No

Ear Tubes *

Yes
No

Liver Biopsy *

Yes
No

Anal/Rectal Surgery *

Yes
No

Esophagus Surgery *

Yes
No

Upper Intestinal Endoscopy *

Yes
No

Appendectomy *

Yes
No

Gastrostomy *

Yes
No

Tongue Tie Repair *

Yes
No

Cleft Lip *

Yes
No

Cleft Palate *

Yes
No

Heart Surgery *

Yes
No

Tonsillectomy *

Yes
No

Colonoscopy *

Yes
No

Hernia Repair *

Yes
No

Additional Medical History

Who lives with patient? *

Mother
Father
Siblings
Other

If other, please list who lives with the patient. *

Activities/Hobbies/Sports

Pets in the home

Family History Questionnaire

Anesthesia Problems

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Celiac Disease

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Colon Cancer

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Colon Polyps

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Constipation

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Crohn's Disease

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Food Allergies

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Gallstones

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

GERD (acid reflux)

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Hepatitis B

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Hepatitis C

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Irritable Bowl Syndrome

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Lactose Intolerance

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Liver Disease

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Migraines

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Stomach Ulcers

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Thyroid Disease

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Ulcerative Colitis

Father
Mother
Brother
Sister
Maternal Grandfather
Paternal Grandfather
Maternal Grandmother
Paternal Grandmother

Prove that you're human. *