21081 S. Western Ave. Suite 150, Torrance, CA 90501

Western Medical Group

Health Questionnaire

  • HISTORY OF PAST ILLNESS: Have you had

  • Childhood
  • Adult
  • Operations
  • Injuries
  • Family History
  • Father (If living)
  • Father (If deceased)
  • Mother (If living)
  • Mother (If deceased)
  • Brother / Sister (If living)
  • Brother / Sister (If deceased)
  • Brother / Sister (If living)
  • Brother / Sister (If deceased)
  • Husband / Wife (If living)
  • Husband / Wife (If deceased)
  • Son / Daughter (If living)
  • Son / Daughter (If deceased)
  • Son / Daughter (If living)
  • Son / Daughter (If deceased)
  • Has any blood relative ever had:
  • Social History

  • Education (Years)
  • SYSTEMIC REVIEW:

    Do you have any of the following?
  • General
  • Skin
  • Head-Eyes-Ears-Nose- Throatz
  • Neck
  • Respiratory
  • Cardiovascular:
  • Gastrointestinal
  • Gynacological
  • Locomotor-Musculoskeletal:
  • Neuro-Psychiatric
  • Hematologic:
  • Allergic:
  • Endocrine:
  • ALLERGIES AND SENSITIVITIES

  • 1. Is there a history of skin reaction or other untoward reaction of sickness following injection or oral administration of:
  • 2. Drugs Recently Taken: Within the past six months has patient taken: