Patient Health Assessment

Patient Name*

First Last

Date of Birth*

1. Have you seen a medical doctor during the past two years?*

Yes
No

2. Have you taken any medicine or drugs during the past two years?*

Yes
No

3. Are you allergic to or made sick by penicillin, aspirin, codeine, or any other drugs or medications?*

Yes
No

4. Have you ever had any excessive bleeding requiring special treatment?*

Yes
No

5. When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest or shortness of breath, or because you are very tired?*

Yes
No

6. Do you ever wake up from sleep short of breath?*

Yes
No

7. WOMEN: Are you pregnant?

Yes
No

8. Are you currently taking any medications?

Yes
No

List of Medications:

Please list each on a separate line.

9. Name of Physician*

Physician's Phone Number

10. Please check any of the following which you have had or have at present:

Heart Failure

Yes

Anemia

Yes

Arthritis

Yes

Heart Disease or Attack

Yes

Stroke

Yes

Rheumatism

Yes

Angina Pectoris

Yes

Kidney Trouble

Yes

Cortisone Medicine

Yes

High Blood Pressure

Yes

Ulcers

Yes

Glaucoma

Yes

Heart Murmur

Yes

Emphysema

Yes

Pain in Jaw Joints

Yes

Rheumatic Fever

Yes

Tuberculosis (TB)

Yes

AIDS

Yes

Congenital Heart Lesions

Yes

Asthma

Yes

Hepatitis A (infectious)

Yes

Scarlet Fever

Yes

Scarlet Fever

Yes

Allergies or Hives

Yes

Hepatitis B (serum)

Yes

Artificial Heart Valve

Yes

Diabetes

Yes

Liver Disease

Yes

Heart Pacemaker

Yes

Thyroid Disease

Yes

Yellow Jaundice

Yes

Heart Surgery

Yes

X-ray or Cobalt Treatmemt

Yes

Blood Transfusion

Yes

Artificial Joint

Yes

Chemotherapy

Yes

Hemophilia

Yes

Cold Sores

Yes

Epilepsy or Seizures

Yes

Dizzy Spells

Yes

Sickle Cell Disease

Yes

Bruise Easily

Yes

Sinus Trouble

Yes

Dr. Signature

Date

Notes:

Patient Health Assessment

Health Assessment 2021

10. Please check any of the following which you have had or have at present:

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