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As per the Centers for Disease Control, everyone present in healthcare facilities should continue to wear masks. The ENIHEALTHCARE appreciates your cooperation.

Call: 936-321-1946

Email: info@doctoreni.com
Fax: 936-321-8271

Email: info@doctoreni.com | Call: 936-321-1946

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MON – FRI: 7:30am – 5pm
SAT– SUN: OFF

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Please Submit Your Health History Form

Health History Form

Health History Form

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My InformationStep 1 of 7

My Information

First Name *

Last Name *

Email *

Date of Birth *

Age *

Date of Last Examination

Reason for Visit

Sex *

Male
Female

Please check any condition that you have.

General

Chills
Depression
Dizziness
Fainting
Fever
Forgetfulness
Headache
Loss of Sleep
Nervousness
Numbness
Sweats

Muscle/Joint/Bone

Arms
Back
Feet
Hands
Hips
Legs
Neck
Shoulders

Pain, weakness, numbness in:

Cardiovascular

Chest Pain
High Blood Pressure
Irregular Heartbeat
Low Blood Pressure
Poor Circulation
Rapid Heartbeat
Swelling of Ankles
Varicose Veins

Genito-Urinary

Blood in Urine
Frequent Urination
Lack of Bladder Control
Painful Urination

Gastrointestinal

Appetite Poor
Bloating
Bowel Changes
Constipation
Diarrhea
Excessive Hunger
Excessive Thirst
Gas
Hemorrhoids
Indigestion
Nausea
Rectal Bleeding
Stomach Pain
Vomiting
Vomiting Blood

Eye, Ear, Nose, Throat

Bleeding Gums
Blurred Vision
Cross Eyes
Difficulty Swallowing
Double Vision
Earache
Ear Discharge
Hay Fever
Hoarseness
Loss of Hearing
Nosebleeds
Persistent Cough
Ringing in Ears
Sinus Problems
Vision – Flashes
Vision – Halos

Skin

Bruise Easily
Hives
Itching
Change in Moles
Rash
Scars
Sore that Won’t Heal

Blood Transfusions *

Yes
No

Have you ever had blood fusion?

Date of Last Blood Transfusion

Men Only

Breast Lump
Erection Difficulties
Lump in Testicles
Penis Discharge
Sore Penis
Other

Women Only

Abnormal Pap Smear
Bleeding between periods
Breast Lump
Extreme Menstrual Pain
Hot Flashes
Nipple Discharge
Painful Intercourse
Vaginal Discharge
Other

Other (men)

Other (Women)

Pregnancies

(I)

Year

Sex

Complications

(II)

Year

Sex

Complications

(III)

Year

Sex

Complications

Medications & Allergies

Pharmacy Name

Pharmacy Phone Number

Medication

Please use comma (,) to separate if you are having more than one Medication

Allergies

Please use comma (,) to separate if you are having more than one Allergy

Relatives

(I)

Relationship

Age

State of Health

Age of Death

Cause of Death

(II)

Relationship

Age

State of Health

Age of Death

Cause of Death

(III)

Relationship

Age

State of Health

Age of Death

Cause of Death

Hospitalizations

(I)

Year

Hospital

Reason

Outcome

(II)

Number

Hospital

Reason

Outcome

Injuries

(I)

Injury

Number

Outcome

(II)

Injury

Number

Outcome

Family Health History

Blood Relative Health Issues

Arthritis,Gout
Asthma,Hay Fever
Cancer
Chemical Dependency
Diabetes
Heart Disease, Stroke
High Blood Pressure
Kidney Disease
Tuberculosis
Other

List condition and relatives with condition.

Relatives with Arthritis,Gout

Relatives with Asthma,Hay Fever

Relatives with Cancer

Relatives with Chemical Dependency

Relatives with Diabetes

Relatives with Heart Disease, Stroke

Relatives with High Blood Pressure

Relatives with Kidney Disease

Relatives with Tuberculosis

Blood Relative Health Issues (Other)

Health Habits

Caffeine
Tobacco
Drugs
Other

Frequency of Caffeine Use

Frequency of Tobacco Use

Frequency of Drugs Use

Frequency of Other Use

Occupation

Occupational Concerns

First Choice
Stress
Hazardous Substances
Heavy Lifting
Other

Occupational Concerns (Other)

Exercise

Yes
No

Do you exercise regularly?

Type of Exercise

Diet

Yes
No

Do you follow a special diet?

Type of Diet

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things *

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed, or hopeless *

Not at all
Several days
More than half the days
Nearly every day

Trouble falling or staying asleep, or sleeping too much *

Not at all
Several days
More than half the days
Nearly every day

Feeling tired or having little energy *

Not at all
Several days
More than half the days
Nearly every day

Poor appetite or overeating *

Not at all
Several days
More than half the days
Nearly every day

Feeling bad about yourself-or that you are a failure or have let yourself or your family down *

Not at all
Several days
More than half the days
Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television *

Not at all
Several days
More than half the days
Nearly every day

Moving or speaking so slowly that other people could have noticed. Or the opposite ? being so fidgety or restless that you have been moving around a lot more than usual *

Not at all
Several days
More than half the days
Nearly every day

Thoughts that you would be better off dead, or of hurting yourself in some way *

Not at all
Several days
More than half the days
Nearly every day

Website

Email

ENIHEALTHCARE has a diverse team of professionals that provide a friendly and welcoming environment along with excellent care for you, your family and associates.

Make An Appointment

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Office Hours

Monday – Friday
7:30am – 5pm

Saturday – Sunday OFF

Location

9319 Pinecroft Drive
Suite 120 The Woodlands
Texas 77380

Contact Us

Call: 936-321-1946
Fax: 936-321-8271

info@doctoreni.com

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