Wholeness Family Clinic Health History - Female
Last Name: ____________________________________ Date of Birth: ___/____/____
First Name(s): __________________________________ d m y
Health Number: ________________________________
Civic Address: __________________________________ Phone #: _______________
PO Box __________________________________ Work #: ________________
Town/P Code __________________________________ Cell #: _________________
Email Address: __________________________________________________________
Marital Status: single married widowed divorced separated
common law same sex
Spouse or Partner’s Name: ________________________
Occupation: ___________________ Employer: __________________________
Have you had (or have) any of the following diseases?
Allergies Chronic Bronchitis High Blood Pressure
Arthritis Diabetes Nerves
Asthma
Heart Trouble Skin Problems
Cancer Other: _______________________________________
Have you had any of the following operations? Indicate which year.
Appendectomy ____ Hysterectomy ____ Gall Bladder ____
Breast Surgery ____ Other: __________________________________
Do you have a strong family history of any of the following?
Cancer Heart Attacks High Blood Pressure
Diabetes Other: ________________________________________
Medications: Please list all the medications that you regularly take.
________________________________________________________________________
________________________________________________________________________
Indicate: number of pregnancies _____ number of living children _____
Allergies: Please list all drug allergies.
________________________________________________________________________
Do you exercise or walk regularly? no once or twice a week
daily very athletic
Do you smoke? never less than 1 pack/day 1 pack/day or more
quit ( # of years___ )
Do you drink alcohol? never regularly (# of drinks / week ___ )
occasionally quit (# of years of sobriety ___ )