Injuries

Did you ever have a serious injury?

Did you ever break any bones?

Were you ever inoculated against tetanus?

Surgery and Hospitalizations

Did you ever have a serious operation?

Was the operation performed on you under anesthetic machine?

When was your appendix removed?

Did you ever lie in the hospital?

When were you vaccinated against cholera, yellow fever?

When were you revaccinated against tetanus?

Do you have an unusual sensitivity to any drug?

Are you allergic to any pollens?

Did you ever receive blood transfusion?

Did you have any complications after blood transfusion (chills, jaundice)?

PERSONAL HISTORY

Marital Status

How many years have you been married?

Is your wife (your husband) in good health?

Are you happily married?

How many children do you have?

How old are your children?

Do you want more children?

Do you prevent pregnancy?

Why are you not married?

Is there a special reason for it?

Do you worry about not being married?

Habits

Do you smoke or drink?

How often do you take alcoholic drink?

Do you get up at night to have a smoke?

Do you smoke on an empty stomach?

Do you take any sedatives?

Do you take any sleeping drugs?

Do you use narcotics?

Do you regularly use unprescribed drugs?

Do you have a good sleep?

Do you suffer from sleeplessness?

Do you go to sleep at once?

Do you sleep soundly?

Do you often wake up at night?

Are you a light sleeper?

Do you have a nap in the middle of the day?

What kind of dreams do you have – fright – tening or pleasant dreams?

Are you often awakened out of your sleep by frightening dreams?

Occupation

What was your first job?

What was its nature and duration?

What other kinds of job have you had?

How long did they last?

Why did you leave?

Are your present work and salary satisfactory?

Do you consider your work too hard or too easy for you?

Do you consider your work a strain?

Do you work under unfavorable hygienic conditions?

Are you exposed to any occupational hazards?

What industrial hazards are there in your enterprise?

Family history and familial tendency

Are your folks (parents) living?

Are they well?

How old are your parents?

What caused your father’s death?

At what age did your mother die?

Do you have brothers and sisters?

Are they in good health?

Does diabetes run in your family?

Does hypertension (high blood pressure) run in your family?

Does TB run in your family?

Did anyone in your family ever have a stroke (apoplexy)?

Does nervousness run in your family?

Does worrying run in your family?

Did anyone in your family ever have a nervous breakdown?

Are headacnes common in your family?

Has anyone in your family ever had fits or convulsions (epilepsy)?

Was anyone in your family ever patient in a mental hospital?

Did anyone in your family ever have tumor or cancer?

Does any other member of your family have similar complaints?

Does stomach trouble run in your family?

Does heart trouble run in your family?

Does rheumatism (arthritis) run in your family?

SYSTEM REVIEW

Do you have headache or pain anywhere in the head?

Is it a burning pain, an aching pain?

Does it feel like a weight on top of the head?

Like a constricting band or like a tight cap?

Is it steady or throbbing?