Confidential History and Physical Questionnaire

Name                                                                Primary Insurance    


Date of Birth                                                        Policyholder        


Place of Birth                                                        Group Number        


Address                                                        Social Security Number        


Marital Status                                                Secondary Insurance    


Occupation                                                        Group Number        


Telephone                                                                  e-mail  


Emergency Contact                                                 Relation:        



Name:                                                                      Telephone:



       Bagheri Medical Group contracts with Medicare only. Patients with all other insurances must pay for
services at the time of their visits. All co-pays and payments for services not covered by medicare are the
responsibility of the patient.




Signature: _____________________________

Name:_______________________________

Please list your chronic medical problems, previous hospitalizations and surgeries:
Date        Illness/Surgery                                Date        Illness/Surgery
                  
                  
                  
                  
                  

Please list the last date you received the following vaccines and screening medical tests:

Vaccines                                               Screening Tests        
Tetanus/Td                                           PPD        
Influenza                                               Blood in Stool        
Pneumonia                                           Cholesterol Panel        
Hepatitis A                                            Mammogram        
Hepatitis B                                            Colonoscopy        
MMR                                                     Cardiac Stress Test
Pertussis                                               Bone Density        

Please list all medications that you are presently taking:

Medications                   Dose/ Frequency                    Duration                                   Reason
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  

Please indicate if you or any close family members suffer or have suffered from any of the following chronic
medical conditions and provide any pertinent details:

Anemia                        
Arthritis                         
Asthma                        
Cancer                        
Depression                        
Diabetes                        
Heart Disease                        
Hepatitis                        
High Blood Pressure                        
High Cholesterol                        
Migraines                        
Osteoporosis                        
Psychiatric Problems                        
Seizures                        
Skin Conditions                        
Stroke                        
Substance Use                        
Thyroid Disease                        
Tuberculosis                        
Visual Problems                        

Please list any vitamins or herbal supplements that you take on a regular
basis____________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Please list all ALLERGIES to foods, medications and environmental allergens:
________________________________________________________________________
Personal Habits:
□ Drink Coffee/Tea: _____ cups per day
□ Smoking: __________cig./day_______________# yrs. Yr
Date you last smoked a cigarette: ___________________
□ Use of Alcohol: _____ Drinks per week
□ Drug Use: ____________
□ Sleep Pattern: ________ Hours per Night, Regular/Irregular
□ Exercise: Type_______ Frequency_______
□ Sexual Activity: Type (heterosexual/homosexual) ________ Frequency_________
□ How many hours of television do you watch every day? _____________________

Please check any of the following symptoms that you regularly experience:

□ ABDOMINAL PAIN
□ BACK PAIN  
□ BLOOD IN URINE                
□ BLOODY OR TARRY STOOLS
□ CHRONIC COUGH        
□ CHEST PAIN        
□ DEPRESSION                        
□ DIFFICULTY SWALLOWING
□ DIZZINESS                          
□ DOUBLE OR BLURRED VISION         
□ FAINTING SPELLS        
□ FATIGUE        
□ HAY FEVER/ALLERGIES         
□ HEADACHES
□ HEARTBURN
□ HIGH BLOOD PRESSURE        
□ IRREGULAR PULSE
□ INSOMNIA
□ IRREGULAR BOWELS
□ LOSS OF APPETITE
□ MEMORY LOSS                
□ MOODINESS                        
□ NERVOUSNESS/Anxiety                
□ NOSE BLEEDS                 
□ PALPITATIONS                
□ RINGING IN EARS                   
□ SHORTNESS OF BREATH
□ SUICIDAL THOUGHTS        
□ SWOLLEN ANKLES
□ URGENCY TO URINATE
□ POOR URINE STREAM
□ NOCTURNAL URINATION
□ WEIGHT LOSS/GAIN
□ WHEEZING

Please elaborate any specific problems you would like to discuss regarding your health, diet or personal habits:
_____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Gynecological (women only):
Menstrual flow: □ Regular □ Irregular □ Pain / cramps
How long do your menstrual periods usually last? ________________
Date of last menstrual period: ______________
Is there any chance you could be pregnant_______
If post-menopausal: age at last period:________ any recent vaginal bleeding___________
Are you now or have you ever been on hormone replacement therapy________________
If yes, for how long________________ When did you stop________________________
Number of Pregnancies: _______ No. of Live births________________
What is your current birth control method?_____________________________________
Are you satisfied with this method?___________________________________________
Date of last PAP: _____________________ □ normal  □ abnormal