Klamath Health Partnership: Health History Questionnaire

Today’s Date:___________ Name:______________________________________ Date of Birth______________

Phone Number:_______________ Age:________ Email address________________________________________

Welcome to Klamath Health Partnership. We have three facilities: Klamath Open Door, Klamath Open Door (Campus) and Chiloquin Open Door
Family Practice. We greatly appreciate you choosing us to provide care for your family. Our clinicians will be asking you about your present medical
condition but allow us to learn more about you, please fill out this questionnaire. Although some questions may be a little startling, please
understand that they address current health issues. These answers are confidential. Thank you for allowing us to participate in your health care.

Past/Current Medical Problems: Past Surgeries:

Allergies To Medications: Current Medications/Vitamins/Herbs:

(List the Drugs and the reaction that you had) (List the drug, the strength & when you take it/why you take it)

Tabacco Use: Alcohol Use:

Cigarettes: ___Never ___Quit (Date:________)
Current Smoker: ______, packs/day for ______ years
Other Tabacco use:
___Pipe ___Cigar ___Snuff ___Chew
Are You Interested In Quitting? ____Yes ____No
Drug Use:
Do you use any recreational drugs? ___Yes ___No
If yes, please list:_____________________________________
Have you ever used any recreational drugs?
______Yes ______No
If yes, what type and when did you quit?
_________________________________________________________
Do you drink Alcohol? ___Yes ___No
If No, did you ever drink? ___Yes ___No
When did you quit? ___________________________________
Number of Alcoholic drinks/week:________________________
Have you ever felt you should cut down on your drinking?
___Yes ___No
Have people annoyed you by criticizing your drinking?
___Yes ___No
Have you felt bad or guilty about your drinking?
___Yes ___No
Have you ever had a drink first thing in the morning to steady
your nerves or get rid of a hangover (eye opener)?
___Yes ___No

For Clinic Use Only: Total CAGE score:_____ (over 2 may indicate need for intervention)

Total PHQ-2: ____ (If yes to either question, administer PHQ-9)

_________Approved with this provider __________Schedule with MD_________ More Information needed __________________

Signature: ______________________________________________
 Klamath Health Partnership: Health History Questionnaire

Occupation/Hobbie: Other Providers:

Specialist(s):________________________________________________
_

__________________________________________________________

Dentist(s):__________________________________________________

Last Dental visit:_____________________________________________

Family History: Preventative Care:
(List any serious health conditions) Last Mammogram: _________________________________________
Your Mother: Any Abnormal Mammograms? _____Yes _____No

Your Father: Last Pap Smear: ___________________________________________

Any Abnormal Pap Smears? _____Yes _____No
Siblings:
Last Bone Density Scan: ____________________________________
Maternal Grandma: Last Colon Cancer Screening (stool cards, sigmoidoscopy, colonoscopy,
etc.) ____________________________________________________
Maternal Grandpa:
Last PSA: (prostate level): ___________________________________
Paternal Grandma If you are male, do you perform a monthly self-testicular exam?
____Yes ____No
Paternal Grandpa:

Screening: Immunizations:
Last Tetanus Vaccination: _________________________________
In the past 2 weeks, have you been bothered by: Last Pertussis Vaccination: _________________________________
Last Pneumonia Vaccination: _______________________________
1. Little Interest or pleasure in doing things? Last Influenza (Flu) Vaccination: _____________________________
_____Yes ______No
If you were born after 1957, have you had a second measles, mumps
2. Feeling down, depressed or hopeless? and rubella vaccination? _____Yes _____No
_____Yes _____No

Women: Other:

Are you pregnant? _______________________________
Number of Total pregnancies: ______________________
Number of Deliveries: ____________________________
Number of Miscarriages: __________________________
Number of Abortions: ____________________________
Last Menstrual Period:____________________________
Do you practice “Safe Sex”? ____Yes ____No
Are you at risk for HIV? ____Yes ____ No
Have you been exposed to chemicals or radiation at the workplace?
____ Yes ____No
Do you have a Living Will or Advance Directive? ____Yes _____No
If there is a gun in your home, is it out of children’s reach and unloaded?
____ Yes ____ No

For Clinic use only: Total CAGE score: ____ (over 2 may indicate need for intervention)

Total PHQ-2 ____ (If yes to either question, administer PHQ-9)

__________ Approved with this provider __________Schedule with MD _____________More information needed ______________

Signature: ________________________________________________