Plaza Infectious Disease, PC

Health Questionnaire

Personal Information

Past History
Medical History - Do you have a history of:






















STD History

Past Surgeries or Trauma History











Vaccination History
Have you had these vaccinations? If so, when was the last dose?









Current Medications
(including vitamins, herbal supplements, non-prescription/over-the-counter)
Have you had allergies to medications?

Family History
Have any of your blood relatives had any of the following (do not list yourself):
  
  
  
  
  
  
  
  
    
    
Please answer the following questions honestly, as this information may be necessary to assure the best treatment. All information will be kept CONFIDENTIAL. Do you:



If you no longer use, enter date quit    
Social History
Are you currently working?


Marital Status





Review of Systems
A review of systems has multiple purposes. It serves as a screening device to uncover potentially significant symptoms and is a vital part of a thorough medical evaluation, so we ask your patience in answering each and every question below. Please discuss any questions you prefer not to answer with your provider or nurse.

Please check Yes for active problems and No for symptoms you are not currently experiencing. Please check New if the problem is bothersome enough to require further evaluation.
Yes   No   New  Constitutional
         Weight Loss
         Fever or chills
         Reduced exercise tolerance
         Abnormal fatigue or weakness
Yes   No   New  Eyes
         Abnormal light sensitivity
         Pain
Yes   No   New  ENT
         Impaired hearing
         Earache
         Discharge
         Congestion
         Dentures
Yes   No   New  Cardiovascular
         Chest pain or tightness
         Chest discomfort with exertion
         Abnormal breathlessness with effort
         Blackouts (fainting spells)
Yes   No   New  Respiratory
         Shortness of breath
         Persistent cough
         Tuberculosis exposure
Yes   No   New  Gastrointestinal
         Nausea or vomiting
         Abdominal pain
         Change in bowel movements
Yes   No   New  Genitourinary
         Urinary urgency
         Painful urination
         Abnormal frequency of urination
         Sexually transmitted disease exposure
         Genital sores or discharge
Yes   No   New  Skin
         Rash
         Itching
Yes   No   New  Neurologic
         Headaches
         Impaired balance or coordination
         Numbness or tingling
         Convulsions/Seizures
Yes   No   New  Musculoskeletal
         Joint pain
         Stiff, swollen or red/warm joints
Yes   No   New  Endocrine
         Excessive thirst or urination
         Lack of sexual desire
Yes   No   New  Psychiatric
         Down, depressed, or hopeless
         Excessive nervousness/stressed
         History of drug/alcohol dependency
Yes   No   New  Hematological/Lymph
         Enlarged lymph nodes
Yes   No   New  Allergic/Immunologic
         Any history of asthma
         Seasonal or all-year allergies
         Frequent bronchitis, pneumonia or sinusitis infections
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