Personal Health History Form

Please rate by circling the following symptoms from 0 (no problem) to 5 (severe problem), when you experience the symptom.

1. Need to Blow Nose*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

2. Sneezing*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

3. Runny Nose*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

4. Cough*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

5. Post-nasal Discharge*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

6. Thick Nasal Discharge*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

7. Ear Fullness*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

8. Dizziness*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

9. Ear Pain*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

10. Facial Pain/Pressure*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

11. Difficulty Falling Asleep*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

12. Wake Up at Night*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

13. Lack of Sleep*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

14. Wake Up Tired*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

15. Fatigue*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

16. Reduced Productivity*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

17. Reduced Concentration*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

18. Frustrated / Restless / Irritable*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

19. Sad*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

20. Embarrassed*

0 - No Problem
1 - Very Mild Problem
2 - Mild or Slight Problem
3 - Moderate Problem
4 - Severe Problem
5 - Problem as Bad as it Can Be

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of the office staff responsible for errors or omissions that I may have made in completing this form.

Signature*

Date*

Step 1 of 9 - Personal Information

Personal Information

Past Medical History

Past Surgical History

Social History

Medications and Medicine Allergies

Family History

Birth History (Patients under 12 years of age)

Review of Symptoms

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