Please note:  This very sensitive information would only be required if a new physician requested a complete history of your life style. This is not something you would complete and provide to anyone else other then a physician upon request. 

Personal Health History Form 

Gender: ______________ Birth date:______________ Age_______ 

Place of birth: _________________________Ethnicity: __________

MEDICAL HISTORY (list your medical history) 

CURRENT CONDITION: (list any current diagnosis) 
Condition(s): ____________________________ Year Diagnosed _____________
Condition(s): ____________________________ Year Diagnosed _____________

PREVIOUS OPERATIONS 
Surgery for: (list operation) ________________________________________
Year _____Hospital _______________________________________________

PREVIOUS INJURIES 
(describe falls, car accidents, work related, etc.)
Year _______ Injury: _______________________________________________
Year _______ Injury: _______________________________________________
Year _______ Injury: _______________________________________________

PREVIOUS MEDICAL CONDITIONS
Year_____ Condition: _________________________________
Year_____ Condition: _________________________________

MENTAL HEALTH 
Condition diagnosed (list, for example depression/anxiety, etc.) List year diagnosed. ______________________________________________________________
______________________________________________________________

SOCIAL HISTORY
Marital status (circle): Married Single Divorced Separated Never Married
Year Married _____________
Year Divorced ____________
Year Widow/Widowed ______
Number of children: _______
Ages and sex _________________________________

SEXUAL HISTORY
Number of lifetime sexual partners: ____
Gender(s) of sexual partners: ( ) Male ( ) Female ( ) Both
Practice safe sex? (  ) Yes (  ) No

WORK HISTORY:
Are you currently employed: (   ) Yes (   ) No 
Type of work performed (describe) ___________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Hours worked per day ________, per week ____

Describe any difficulties experiencing in performing work:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Have you every been evaluated by a Occupational Therapist?
(     ) Yes    (     ) No
If yes, when:______________________________________
Name and contact of therapist:
Name_______________________
Phone Number________________

PREVENTATIVE HEALTH HISTORY 

TOBACCO: 
Have you ever used tobacco products? (   ) Yes (   ) No
No. of cigarettes smoked per day: ____
No. of cigars smoked per day: ____
No. of years smoked: ____
Have you ever quit? (   ) Yes (   ) No

ALCOHOL (beer, liquor, wine) 
No. of drinks _____ per day _____ per week 
Have you ever quit? 
(   ) Yes (   ) No
Have you abused alcohol? 
(   ) Yes (   ) No
Has your job performance ever been affected by alcohol: 
(   ) Yes (   ) No
Has your marriage/relationship every been affected: 
(   ) Yes (   ) No
Family or social relationships affected by alcohol: 
(   ) Yes (   ) No
Have you every experienced a blackout: 
(   ) Yes (   ) No
If yes, how often ______________________

DRUGS
(marijuana, cocaine, amphetamines, heroin, etc) 
Have you ever used drugs? (   ) Yes (   ) No
Which drug(s) have you used? ____________________________
When was your last use? _________________________________
EXERCISE 
Do you regularly exercise? (   ) Yes (   ) No
If yes, what type of exercise(s) (describe)?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
How often do you exercise per week? _______
Length of exercise sessions: _________

Have you been assessed by a Physical Therapist: (   ) Yes (   ) No
If yes:
Name:___________________
City/State:_______________
Phone:___________________

Are you currently seeing this therapist? _____
Name:___________________
City/State:_______________
Phone:___________________
When was your last appointment? __________

SAFETY 
Check items that are applicable to you:

Unsteady Gait: (   ) Yes (   ) No
Difficulty Walking: (   ) Yes (   ) No

Falls: (   ) Yes (   ) No
Frequency: ____________________

Dizziness: (   ) Yes (   ) No
Frequency: ____________________

Drives: ( ) Yes ( ) No
Frequency: ____________________
Normal Distance: ______________
Seat-belt use: (   ) Yes (   ) No

Smoke alarm in home? ( ) Yes ( ) No

Gun Ownership 
Do you keep a gun in the home? (   ) Yes (   ) No
If yes, is it locked? (   ) Yes (   ) No
If yes, is it loaded? (   ) Yes (   ) No

DIET

Difficulty Swallowing: ( ) Yes ( ) No 
If yes, extent (identify liquids, type of food, etc.): 
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Speech/Swallowing Therapy Assessed: (  ) Yes (  ) No 
Clinical Dietician Assessment Performed: (  ) Yes (  ) No 
Number of meals each day: ____
Average length of each meal: ____
Glasses of water per day: ____
No. of snacks per day: ____
No. of servings of fruits per day: ____
No. of servings of vegetables per day: ____
No. of servings of meat per day: ____
No. of servings of dairy products per day: ____
Average Calory Consumption per day:____

FAMILY HISTORY 
(consider neurological disease, heart disease, diabetes, cancer) 

Father Living (   ) Yes Current Age______  (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Mother Living (   ) Yes Current Age______ (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Spouse Living (   ) Yes Current Age______ (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Children Living (   ) Yes Current Age______ (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Children Living (   ) Yes Current Age______ (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Children Living (   ) Yes Current Age______ (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Brother(s) (   ) Yes Current Age______ (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Sister(s) Living (   ) Yes Current Age______ (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Paternal-Grandfather Living (   ) Yes Current Age______ (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Paternal-Grandmother Living (   ) Yes Current Age______ (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Maternal-Grandfather Living (   ) Yes Current Age______ (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Maternal-Grandmother Living (   ) Yes Current Age______ (   ) No  Age at death ____
Medical conditions and/or cause of death _____________________________

Identifiy any Uncles and Aunts, additional children, brothers, sisters, etc. and identify any
Known medical condition(s):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

HOBBIES: Describe what activities you like to do in your free time:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________