HEALTH HISTORY QUESTIONNAIRE

Name: _________________________________________ D. O. B.: ____________ Date: _______________

Primary Care Physician: ____________________________ Referring Physician: ______________________

Pharmacy Name and Address: ______________________________________________________________

Medical Equipment Company (oxygen, nebulizer, CPAP, BiPAP): __________________________________

Reason for Visit: ________________________________________________________________________

Review of Systems: Check all symptoms you’ve had in the past six months:

General: HEENT Cont: Gastrointestinal: Psychiatric: □ Abdominal Pain□ Heartburn□ Nausea□ Vomiting

□ Depression□ Memory Loss□ Nervousness------------------------------------------Endocrine:---------------------------

Musculoskeletal:

□ Appetite Loss□ Daytime Sleepiness□ Fatigue□ Fever□ Night Sweats□ Trouble Sleeping□ Significant Weight Gain□ Significant Weight Loss□ Unable to Sleep Lying Flat

□ Back Pain□ Joint Pain□ Muscle Pain

□ Excessive Thirst□ Excessive Urination at Night□ Thyroid Problems------------------------------------------

Hematology: ------------------------------------- Skin:

---------------------------

□ Seasonal Allergies□ Snoring□ Sore Throat□ Visual Loss-----------------------------------Respiratory:□ Cough□ Coughing up Blood□ Shortness of Breath□ Sputum Production□ Wake up Short of Breath Neurological:

□ Itching□ Rash

□ Wheezing-----------------------------------

------------------------------------- Cardiovascular: HEENT:

□ Dizziness□ Headaches□ Numbness□ Seizures□ Stroke

□ Glaucoma□ Hoarseness□ Nasal

Congestion□ Runny Nose

□ Abnormal Blood Pressure□ Chest Pain □ Heart Failure□ Palpitations□ Swelling of Extremities

□ Abnormal Bleeding□ Anemia□ Easy Bruising------------------------------------------Genitourinary:□ Menstrual Irregularities□ Prostate Problems□ Urinary Frequency□ Urinary Urgency

Past Medical Conditions:__________________________________________________________

SocialHave you ever smoked?

How many years have you smoked?

If quit, when?

How many packs a day?

Lived with someone who smokes?

Exposure to second hand smoke?

Exposure to toxic chemicals or substances?

Alcohol use:

If you used to drink, when did you stop?

What do you drink?

No. of times per week?

□ yes □ no

_________

_________

_________

□ yes □ no

□ yes □ no

□ yes □ no

□ yes □ no

_______________

________________________________________

_________

□ yes □ no

□ Medicine □ Coffee □ Tea □ Soda □ Foods

_________□ yes □ no

_____________________

_______________________________________

□ Single □ Married □ Separated □ Widowed □ Divorced

□ yes □ no

□ yes □ no

Marijuana or hard drugs use:

Caffeine use:

Amount per day?

Within 2 hrs of sleep?:

How many hours do you sleep a night?

Occupation (if retired, past occupation):

Marital Status:

Pets:

Do you exercise?

Past Surgical: Date: _____________________________

Type of Operation:____________________________________ ________________________________________________ ________________________________________________

Allergies: List your allergies (medications, chemicals, food, etc.)

____________________________________________________________________________________________________________________________________________________Medications: List your current prescription and non-prescription drugs or attach a list if more room is needed. Name Dosage Times per Day

_____________ _______________ _____________ _______________ _____________ _______________

________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________

_______________________________________

_____________________________________________

Travel: Date and place outside of the country in the last two years:_____________________________________

_____________________________________________________________________________________________

TB skin test: When? __________Health Maintenance

Flu shot: When? __________ Pneumovax: When? __________ Results: □ positive □ negative

Pregnancy: Are you currently pregnant? □ yes □ no

Other Past Medical History: __________________________________________________

Father Mother Brother Sister Son Daughter Asthma □ □ □ □ □ □ Stroke □ □ □ □ □ □ Diabetes □ □ □ □ □ □ Emphysema □ □ □ □ □ □ Heart Disease □ □ □ □ □ □ High Blood Pressure □ □ □ □ □ □ Insomnia □ □ □ □ □ □ Kidney Disease □ □ □ □ □ □ Narcolepsy □ □ □ □ □ □ Pulmonary Fibrosis □ □ □ □ □ □ Restless Legs Syndrome □ □ □ □ □ □ Seizure Disorder □ □ □ □ □ □ Sleep Apnea □ □ □ □ □ □ Thyroid Problems □ □ □ □ □ □ Lung Cancer □ □ □ □ □ □ Other Cancer □ □ □ □ □ □

Family History

Most Recent Tests: Date Location

Chest X-Ray: __________ ____________________________________

CT Scan ______________ ____________________________________________________

Ultrasound: ______________ ____________________________________________________

MRI: ______________ ____________________________________________________

Breathing Test: ______________ ____________________________________________________

Sleep Test: ______________ ____________________________________________________

Lab Work: ______________ ____________________________________________________

1. Do you snore? □ Yes □ No □ Don’t knowIn which position do you snore? Is it worse on your back? Do you snore if you fall asleep in a chair? Does your snoring disturb anyone? Has anyone ever noticed if you stop breathing in your sleep? Do you gasp or choke while you sleep? Does anyone sleep in your bedroom with you?

□ Back only □ All positions□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No

2. Do you suffer from either of the following in the morning?

3. Do you feel sleepy during the daytime?

□ Dry mouth □ Headache

□ Yes □ No □ Don’t know

How many days per week? ______What age did it start? ______ Is it worsening? □ Yes □ No □ Don’t know

□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know

4. Have you ever had a car accident due to sleepiness?5. Do you suffer from memory problems?6. Do you ever “zone out”?7. Are you more irritable lately?8. Do you take any daytime naps?

Sleep History

How many per week? ______________ How long do you nap? _____________ Are your naps refreshing? □ Yes □ No

9. Rate the severity of your sleepiness (1 = no sleepiness and 10 = very severe sleepiness): _______

□ Yes □ No

□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know□ Yes □ No □ Don’t know

12. Have you ever felt paralyzed when waking up or falling asleep?

13. Do you ever dream while you are falling asleep or napping?14. Do you walk or talk in your sleep?15. Do you ever accidentally urinate in bed?16. Do you have nightmares?17. Have you ever injured yourself or others while asleep?

18. What is your bedtime? _____________

11. Have you ever felt a sudden loss of strength while experiencing a strong emotion (ie. fear, surprise, laughter)?□ Yes □ No

10. Do you ever have restlessness or discomfort in your legs? □ Yes □ No

When? _____________________ What do you do to relieve it? __________________How often does it occur? ___________________ Does it interfere with your sleep? □ Do you move or kick your legs while sleeping? □

Yes □ No

Yes □ No □ Don’t know

How long does it take you to fall asleep? ________________When do you wake up? _____________________Do you wake up during the night? □ Yes □ No □ Don’t know

How many times per night? ________ What awakens you? _________________________

19. Work hours (if applicable): ____________________If you do not work, how do you occupy your days? _________________________________What do you do in the evenings? ____________________________________________

20. How likely are you to doze off or fall asleep in the following situations?

0 = Would NEVER doze 1= SLIGHT chance of dozing 2 = MODERATE chance of dozing 3 = HIGH chance of dozing

Situation Chance of Dozing

Sitting and reading 0 1 2 3

Watching TV 0 1 2 3

Sitting, inactive in a public place (e.g. a theater or a meeting) 0 1 2 3

As a passenger in a car for an hour, without a break 0 1 2 3

Lying down to rest in the afternoon, when circumstance permit 0 1 2 3

Sitting and talking to someone 0 1 2 3

Sitting quietly after a lunch without having had any alcohol 0 1 2 3

In a car, while stopped for a few minutes in traffic 0 1 2 3

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