Dr. Don F. Marx - Medical Questionnaire Form

Medical Questionnaire:

Patient Name

Today's Date

Reason for Visit

1.	Your family doctor
	Last medical exam
2.	Are you taking medications?	None Yes
	If yes, Please list your medications:




3.	Are you allergic to any medications?	No Yes
	If yes, Please choose:	Penicillin Sulfa Codeine Aspirin Iodine Other
4.	Select any surgeries that apply to you:	None Tonsillectomy Sinus Lung Heart Bypass Pacemaker Appendectomy Hysterectomy Tubal Ligation C-Section Hernia Gall Bladder Breast Biopsy Mastectomy Prostate Biopsy TURP Other
5.	Is there a family history of urinary problems?	Yes No If yes, what family member(s)?

General

Fever Diabetes High Blood Pressure Arthritis Osteoporosis
Skin Rash Depression Stroke Thyroid Disease
Alzhcimer's Seizures Hepatitis No prior general health problems
Other

Social

Alcohol Use: regularly occasionally socially only non-drinker
Do you smoke?: No Yes packs per day for years
Stopped Smoking
Drug Use: Past Occasionally
STD: Venereal Disease Herpes

Kidneys

Burning Kidney Stones Blood in Urine Frequent Infections
Painful Urination Leaking Prostate Problems
Frequent Urination No prior kidney problems
Other

Heart

Chest Pain Heart Attack Rheurnatic fever Cardiac Arrest
Heart Murmur Irregular heart beat Legs Swell
No prior heart problems
Other

Stomach

Ulcers Weight Loss Irritable Bowel Liver Problems
Hernia Diverticulitis Colon Problems
Rectal Bleeding No prior stomach problems
Other

Lungs

Asthma Shortness of Breath Emphysema Pneumonia
Tuberculosis No prior lung problems
Other

Head & Neck

Blindness Lens Implants Contact Lenses Glasses
Sinus Infections Deafness Hearing Aids Migraine Headaches
No prior head or neck problems
Other

Men

Prostatitis Sexual Dysfunction No prior male problems
Other

Women

Last menstrual period
Do you take birth control pills?
Are you pregnant?
No prior female problems
Other