Confidential History and Physical Questionnaire
Name Primary Insurance
Date of Birth Policyholder
Place of Birth Group Number
Address Social Security Number
Marital Status Secondary Insurance
Occupation Group Number
Telephone e-mail
Emergency Contact Relation:
Name: Telephone:
I recognize that Bagheri Medical Group only contracts with Medicare and some HMO's through CCPN. I
recognize that it is my responsibility to insure that I have one of these insurances as my primary health
insurance. I recognize that Bagheri Medical Group accepts assignment at contracted rates for these
insurances. I agree to pay all co-pays according to my insurance policy at the time of each visit
I do not have either one of the above forms of health insurance. I agree to pay for all services rendered at
the time of each visit. I will be charged at a discounted rate equivalent to San Francisco Medicare rates for all
services provided. If I fail to make payment at the time of the visit I will lose this discount and will be responsible
for paying billed charges within 2 weeks of the visit.
Signature: _____________________________
Please indicate if you or any close family members suffer or have suffered from any of the following chronic
medical conditions and provide any pertinent details:
Anemia
Arthritis
Asthma
Cancer
Depression
Diabetes
Heart Disease
Hepatitis
High Blood Pressure
High Cholesterol
Migraines
Osteoporosis
Psychiatric Problems
Seizures
Skin Conditions
Stroke
Substance Use
Thyroid Disease
Tuberculosis
Visual Problems
Please list any vitamins or herbal supplements that you take on a regular
basis____________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please list all ALLERGIES to foods, medications and environmental allergens:
________________________________________________________________________
Personal Habits:
□ Drink Coffee/Tea: _____ cups per day
□ Smoking: __________cig./day_______________# yrs. Yr
Date you last smoked a cigarette: ___________________
□ Use of Alcohol: _____ Drinks per week
□ Drug Use: ____________
□ Sleep Pattern: ________ Hours per Night, Regular/Irregular
□ Exercise: Type_______ Frequency_______
□ Sexual Activity: Type (heterosexual/homosexual) ________ Frequency_________
□ How many hours of television do you watch every day? _____________________
Please check any of the following symptoms that you regularly experience:
□ ABDOMINAL PAIN
□ BACK PAIN
□ BLOOD IN URINE
□ BLOODY OR TARRY STOOLS
□ CHRONIC COUGH
□ CHEST PAIN
□ DEPRESSION
□ DIFFICULTY SWALLOWING
□ DIZZINESS
□ DOUBLE OR BLURRED VISION
□ FAINTING SPELLS
□ FATIGUE
□ HAY FEVER/ALLERGIES
□ HEADACHES
□ HEARTBURN
□ HIGH BLOOD PRESSURE
□ IRREGULAR PULSE
□ INSOMNIA
□ IRREGULAR BOWELS
□ LOSS OF APPETITE
□ MEMORY LOSS
□ MOODINESS
□ NERVOUSNESS/Anxiety
□ NOSE BLEEDS
□ PALPITATIONS
□ RINGING IN EARS
□ SHORTNESS OF BREATH
□ SUICIDAL THOUGHTS
□ SWOLLEN ANKLES
□ URGENCY TO URINATE
□ POOR URINE STREAM
□ NOCTURNAL URINATION
□ WEIGHT LOSS
□ WEIGHT GAIN
□ WHEEZING
Please elaborate any specific problems you would like to discuss regarding your health, diet or personal habits:
_____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Gynecological (women only):
Menstrual flow: □ Regular □ Irregular □ Pain / cramps
How long do your menstrual periods usually last? ________________
Date of last menstrual period: ______________
Is there any chance you could be pregnant_______
If post-menopausal: age at last period:________ any recent vaginal bleeding___________
Are you now or have you ever been on hormone replacement therapy________________
If yes, for how long________________ When did you stop________________________
Number of Pregnancies: _______ No. of Live births________________
What is your current birth control method?_____________________________________
Are you satisfied with this method?___________________________________________
Date of last PAP: _____________________ □ normal □ abnormal
Name:_______________________________
Please list your chronic medical problems, previous hospitalizations and surgeries:
Date Illness/Surgery Date Illness/Surgery
Please list the last date you received the following vaccines and screening medical tests:
Vaccines Screening Tests
Tetanus/Td PPD
Influenza Blood in Stool
Pneumonia Cholesterol Panel
Hepatitis A Mammogram
Hepatitis B Colonoscopy
MMR Cardiac Stress Test
Please list all medications that you are presently taking:
Medications Dose/ Frequency Duration Reason