THS.Physical Health Questionnaire

Teri's Health Services

Questionnaire
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical History
Check all those that apply

Arthritis/GoutAsthmaBlood clotsCirculation problemsColitis/bowel diseaseCongestive heart failure (CHF)Coronary artery disease (CAD)COVID-19/Flu-currentDiabetesEmphysema/COPDHeart attackHeartburn/GERDHigh blood pressureHIV/AIDSRenal failure or diseaseStomach ulcersStrokeThyroid diseaseTuberculosisUrinary tract infection (UTI)NoneOther
Surgical History - check all that apply

No surgical historyAbdominal surgeryAppendectomyBrainBreast biopsyBroken bones/fracturesCABG/Heart bypassCardiac stentColon removalC-sectionGall bladder removalHernia repairHysterectomyJoint replacementMastectomyTonsillectomyVasectomyOther
Are you currently pregnant or may be pregnant or breast feeding?*

YesNo
Do you have a history of cancer and/or undergoing chemotherapy?*

YesNo
If yes to chemotherapy, have you received chemotherapy, or are you scheduled to start chemotherapy, within the past/next two (2) weeks?

YesNoN/A
Do you currently or in the past use nicotine?

Yes in the past I did, but no longer use nicotine of any typeYes I currently use nicotineNo I never used nicotine in the past and I currently do not use nicotineOther
Do you have any of these symptoms? Check all that apply.*

Fever/chillsFatigueWeight loss or gain of 5 lbs or moreHave none of these symptomsOther
Do you have any of these listed symptoms regarding eyes/ears/nose/throat? Check all that apply.*

Vision changePain in eyesHearing problems or ear issuesSmell and nose problemsDizzinessSinus congestion/pressureSwelling/lumps in throatProblems with your throat or swallowingI have none of these symptomsOther
Do you have any of these cardiovascular symptoms? check all that apply.*

Chest painPalpitationsEdema/Swelling in legsI have none of these symptomsOther
Do you have any of these respiratory symptoms? Check all that apply.*

Abdominal painConstipationHeartburn/ingestionDifficulty swallowingNausea/vomitingFrequent urinationPainful urinationBlood in urine or stoolUrinary or stool incontinenceI have none of theseOther
Do you have any of these musculoskeletal symptoms? check all that apply.*

Back or neck painJoint pain or swellingMuscle painI have none of these symptomsOther
Do you have any of these skin symptoms? check all that apply.

RashSkin growthNew or changed molesPersistent itchI have none of these symptomsOther
Do you have any of these neurological symptoms? check all that apply.

HeadachesChange in thinking or processingMemory lossTrouble speakingWeaknessLoss of coordinationNumbnessFalling or unsteady gateI have none of these symptomsOther
Do you have any of these endocrine symptoms? check all that apply.

Excessive/increased thirstHeat/cold intoleranceToo hot or too coldI have none of these symptomsOther
Current weight
Current height
Any concerns about your mental health?
Any concerns about your physical health?
Do you have a history of alcohol abuse or illegal drug use?

YesNo
Have you ever been hospitalized?

YesNo
Do you have any self-declared disabilities? If yes, explain
Do you use nicotine? If yes, history of use and amount.
What is your current or past occupation?
If the person completing form is not the person signing up for treatment, what relationship are you to Client?
Signature*

Clear
Date*

MonthDayYear
Date
Guardian

First NameLast Name
Signature

Clear
Should be Empty:

Teri's Health Services

Medical History