Wellness Family Medicine
HEALTH QUESTIONNAIRE
NAME:                                                                         SSN:
DATE OF BIRTH:                                     PHONE:                                       MARITAL STATUS:
ADDRESS:                                                                                                  SEX:  MALE    FEMALE
Job Title
#	Do you have or have you ever had the following?  (Please check the appropriate box for each item.)	Now	Past	Never	Please supply details in the space below for questions where "Now" or "Past" is checked.  List by question number.
1	High blood pressure
2	Heart attack or other heart problem
3	Heart murmur
4	Cough that lasted more than a month
5	Chest pain
6	Shortness of breath
7	Palpitations or irregular heart beat
8	Bleeding tendency
9	Cancer or tumors
10	Diabetes (“sugar”)
11	Vision problems, including glasses or contacts
12	Eye problems, diseases or injuries
13	Hernia or rupture.
14	Hearing problems
15	Use of tobacco products
16	Any problems with kidneys or bladder, including frequent infections
17	Ulcer or vomiting blood
18	Liver disease or Hepatitis
19	Bowel Changes/Rectal Bleeding
20	Diarrhea for more than three days
21	Hepatitis B vaccine
22	Tuberculosis
23	Chickenpox
24	HIV infection / AIDS
25	TB test in the last year
26	Positive TB skin test
27	Back problems or pain
28	Trouble bending or twisting
29	Lower or upper back injury
30	Leg pain or numbness
31	Neck problems or pain
32	Pain or difficulty with neck movement
33	Neck injury
34	Arm pain or numbness
35	Spine surgery
36	Shoulder pain or limited motion
37	Shoulder surgery
38	Shoulder injury
39	Knee pain, swelling, locking or weakness
40	Knee surgery
41	Knee injury
42	Carpal tunnel syndrome diagnosis, treatment or surgery
43	Numbness or pain of the hands or wrists
Name:                                                     SSN:                                        Date:
#	Do you have or have you ever had the following?  (Please check the appropriate box for each item.)	Now	Past	Never	Give details by question number for "Now", "Past" or "Yes."
44	Fractures or broken bones
45	Other injury or problem with arms or legs
46	Arthritis or joint problems
47	Ankle or foot problems
48	Alcoholism or Drinking Problem
49	Frequent or severe headaches/migraines
50	Brain or Nervous System Problems
51	Psychiatric or emotional disorder
52	Dizziness or fainting
53	Epilepsy, seizures or fits
54	Stroke
55	Head injury
56	Drug abuse treatment
57	Muscle weakness
58	Problems with balance or coordination
59	Tremor or shaking
60	Difficulty walking more than a block
61	Exposure to hazardous chemicals, drugs or dust
62	Allergies to medications, latex, foods, pollens, danders, cosmetics, jewelry or other substances
63	Atopic dermatitis, psoriasis or eczema
64	Other rash or skin problem
65	Asthma, wheezing or hay fever
66	Intolerance to perfumes or strong scents
67	Other serious disease
68	Other surgery
69	Other hospitalized overnight
70	Other health problem or concern
	Please answer "Yes" or "No"	Yes	No
71	Have you ever had a work injury or Worker’s Compensation claim?
72	Have you ever been refused employment or been unable to hold a job (including military) because of:
73	a. Sensitivity to chemicals, latex, etc.
74	b. Inability to perform certain motions
75	c. Other physical or mental reasons
76	Have you ever required special or restricted job assignments due to illness, injury, or physical impairments?
77	Have you had a previous job with similar physical demands?
78	Are you under a doctor’s care?
79	Lost 10 pounds or more in the last year
80	Are you pregnant?
List all medications you have taken in last month:
I hereby affirm that the information above is true to the best of my knowledge and belief.  I agree that any false statement or misrepresentation will be cause for dismissal.   Date _____________  Signature ________________________________