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: __________________________

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PCP’s location:  ________________________

Current medications (including prescription, over-
the-counter, and alternative): _______________

Do you have a history of...
...epilepsy/seizures?yesno


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...sleep apnea?yesno
...snoring?yesno


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...daytime fatigue?yesno
...diabetes?yesno


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...high blood pressure?yesno
...heart problems?yesno


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Other medical illnesses:  _________________

Surgical history:  __________________________

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   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

_____

________________________

_____

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Father

_____

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_____

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Brothers/

_____

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_____

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Sisters

_____

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_____

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_____

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Children

_____

________________________

_____

____________________________

_____

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_____

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_____

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