Health History Questionnaire page 1
Before filling out any questionnaires, please print and sign the forms under the Patient Forms tab at http://www.drjonesbailey.com. Bring them to your next appointment with Dr. Alise Jones-Bailey. Thank you.
Patient Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
I am primarily interested in: *
Required
I am primarily interested in: (other)
Your answer
My Desired Goals:
Your answer
List Allergies
Your answer
Last Physical Exam Date:
MM
/
DD
/
YYYY
List Surgeries/hospitalizations
Your answer
Medical History: Have you ever had or do now:
Females only: Check all that apply
Have you periods stopped? If yes, when?
Your answer
How old were you when your periods first began?
Your answer
How many times have you been pregnant?
How many live babies have you delivered?
How many miscarriages have you have?
How many abortions have you had?
Questions for all: Check all that apply:
Please list all prescriptions:
Your answer
Please list all vitamins/supplements/herbs:
Your answer
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