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Medical Questionnaire

  Use this to enroll before visiting with Dr. Tanenbaum or to update your
Current Health Condition.

  Instructions: This form contains a large number of questions about your current health that will assist us in helping you.  You must provide a response to all questions.  Please be as complete as possible. Please fill out the registration form first, if you are new.
  It will require 10-15 minutes to complete this form.  This form consists of the data entry page below and a formatted results page for printing. The formatted results page presents the questions in a different order for Dr. Tanenbaum. So it is easier to review your answers on this page rather than on the formatted page you sign. All of this information is deleted from the computer after you print out the formatted page or reset the form!
  Try to finish all questions before browsing elsewhere or closing your browser session.  If your session is interrupted all data will be lost and you will be required to re-enter it all.  This data feature protects your privacy by discarding data from our systems when you are done.
  Use the "Format" or "Continue" buttons at the bottom of each page to move forward.  Use your Browser's "Back" button to review or make changes to a previous page.  
  Please fill out all required* fields so we may correctly identify you.
(terms of use)

 
  Patient Information:
First Name*

Middle

Last Name*
Home Phone xxx-xxx-xxxx :* 
Soc. Sec. Nr. xxx-yy-zzzz :*    

 

Health Review of your Systems:

 
Instructions: Please select an answer for each question plus provide additional information where appropriate.   Possible Selections include: Yes, No, ?(not sure or don't know) or Dec (Decline to answer).  
  A selection is required for all questions*.  NA is used in gender specific questions.  Change NA to your answer in sections that apply to you.
Y
E
S 		N
O 		?   D
e
c
1 Are you troubled with stiff or painful joints?  
2 Are your joints ever swollen?  
3 Are you troubled by pains in the back or shoulder?  
4 Are your feet often painful?  
5 Are you handicapped in any way?  
         
6 Do you have any skin problems?  
7 Does your skin itch or burn?  
8 Do you have trouble stopping even a small cut from bleeding?  
9 Do you bruise easily?  
         
10 Do you ever faint or feel faint?  
11 Is any part of your body always numb?  
12 Have you ever had seizures or convulsions?  
13 Has your handwriting changed recently?  
14 Do you have a tendency to shake or tremble?  
Y
E
S 		N
O 		?   D
e
c
15 Are you very nervous around strangers?  
16 Do you find it hard to make decisions?  
17 Do you find it hard to concentrate or remember?  
18 Do you usually feel lonely or depressed?  
19 Do you often cry?  
20 Would you say you have a hopeless outlook?  
21 Do you have difficulty relaxing?  
22 Do you have a tendency to worry a lot?  
23 Are you troubled by frightening dreams or thoughts?  
24 Do you have a tendency to be shy or sensitive?  
25 Do you have a strong dislike for criticism?  
26 Do you lose your temper often?  
27 Do little things often annoy you?  
28 Are you disturbed by any work or family problems?  
29 Are you having any sexual difficulties?  
30 Have you ever considered committing suicide?  
31 Have you ever desired or sought psychiatric help?  
Y
E
S 		N
O 		?   D
e
c
32 Have you gained or lost over 10 pounds in the last 6 months?  
33 Do you have a tendency to be too hot or too cold?  
34 Have you lost your interest in eating lately?  
35 Do you always seem to be hungry?  
36 Are you more thirsty than usual lately?  
37 Are there any swellings in your armpits or groin?  
38 Do you feel exhausted or fatigued most of the time?  
39 Do you have difficulty either falling asleep or staying asleep?  
40 Do you participate in physical activity or exercise less than three times a week?    
41 Do you drive a motor vehicle more than 25,000 miles a year?    
42 How often do you use seat belts when riding in cars?  Always, Never, Sometimess  
43 Have you traveled outside of the United States in the past six months?
If YES, list countries visited   		   
Y
E
S 		N
O 		?    D
e
c
44 Are you troubled by heart burn?  
45 Do you feel bloated after eating?  
46 Are you troubled by belching?  
47 Do you suffer discomfort in the pit of your stomach?  
48 Do you easily become nauseated (feel like vomiting)?  
49 Have you ever vomited blood?  
50 Is it difficult or painful for you to swallow?  
51 Are you constipated more than twice a month?  
52 Are your bowel movements ever loose for more than one day?  
53 Are your bowel movements ever black or bloody?  
54 Are your bowel movements ever grey in color?  
55 Do you suffer pains when you move your bowels?  
56 Have you had any bleeding from your rectum?  
Y
E
S 		N
O 		?   D
e
c
57 Do you frequently get up at night to urinate?  
58 Do you urinate more than five or six times a day?  
59 Do you wet your pants or wet your bed?  
60 Have you ever had burning or pains when you urinate?  
61 Has your urine ever been brown, black or bloody?  
62 Do you have any difficulty starting your urine flow?  
63