Driscoll Children’s Craniofacial and Cleft Center

Patient Health Questionnaire (2 of 3 forms)
(Please print this form and fill in all blanks before your first visit)

ALLERGIES:

Do you or have you ever had any allergies? Yes_____ No_____
If yes please list and give type of reaction:
__________________________________________________________
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FAMILY HISTORY:

Have any blood relatives had:
Diabetes? Yes_____ No_____
Cancer? Yes_____ No_____
Other? ____________________________________________
Who? _____________________________________________

MEDICATIONS:

Are you taking medications for any of the following conditions?
High Blood Pressure Diabetes Anemia Nervousness Sleep Heart Disease Thyroid Pain Killers Birth Control Menopause Other Medications	Yes ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___	No ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___	Medication (please list) ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________

PAST OPERATIONS:

Have you ever had any operations? Yes____ No____ If yes please list below:
Year ___________ ___________ ___________ ___________	Operation _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________

MAJOR ILLNESSES:

Have you ever had any of the following?

Illness
Heart Disease
High Blood Pressure
Angina
Ulcers
Colitis
Cancer
Diabetes
Kidney Disease
Thyroid:
Over-active
Under-active
Arthritis
Convulsions

Yes
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No
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Date
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Nervous Breakdown
Depression
Jaundice
Hepatitis
Glaucoma
Cataract
Scarlet Fever
Rheumatic Fever
Tuberculosis (TB)
Other:
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Yes
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No
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Date
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ADDITIONAL: Do you smoke? Yes___ No___ Do you drink alcohol? Yes___ No___
Have you ever used any illegal or narcotic drugs? Yes___ No___

When was your most recent: Chest x-ray? _______ EKG?_______ Complete Physical _______
Please include any other medical condition, illness, or handicap that you may have: ____________________ _____________________________________________________________________________________ _____________________________________________________________________________________

____________________________________________	________________________	____ / ____ / ____
SIGNATURE	RELATIONSHIP TO PATIENT	DATE

Family Medical History Form
Patient Health Medical History
Patient Information
Photo Release Form