MEDICAL QUESTIONNAIRE

Please complete this questionnaire prior to your first session.  You may do so in the waiting room before the session but are encouraged to complete the questionnaire prior to your arrival in the office.  You may print this questionnaire by clicking here.

Name:  _______________________________	Today's date: _____________________________
Date of birth:  __________________________	Place of birth:  ____________________________
Marital status:  _________________________	Occupation: ______________________________
Years of education: _____________________	Medication allergies: _______________________
PCP's name: __________________________	________________________________________
PCP's location:  ________________________	Current medications (including prescription, over- the-counter, and alternative): _______________
Do you have a history of... ...epilepsy/seizures?yesno	________________________________________
...sleep apnea?yesno ...snoring?yesno	________________________________________
...daytime fatigue?yesno ...diabetes?yesno	________________________________________
...high blood pressure?yesno ...heart problems?yesno	________________________________________
Other medical illnesses:  _________________	Surgical history:  __________________________
_____________________________________	________________________________________
_____________________________________	________________________________________
_____________________________________	________________________________________

Family	(if living, note current age and any health problems)		(if deceased, indicate age and cause of death)
History	Age	Health problems	Age	Cause of death
Mother	_____	________________________	_____	____________________________
Father	_____	________________________	_____	____________________________
Brothers/	_____	________________________	_____	____________________________
Sisters	_____	________________________	_____	____________________________
	_____	________________________	_____	____________________________
	_____	________________________	_____	____________________________
	_____	________________________	_____	____________________________
	_____	________________________	_____	____________________________
Children	_____	________________________	_____	____________________________
	_____	________________________	_____	____________________________
	_____	________________________	_____	____________________________
	_____	________________________	_____	____________________________
	_____	________________________	_____	____________________________