Self Health History Form

Get your own Self Health Check Up Online today, to check your own health condition from home or cell phone.

We guide you along the way to help you find out what you want to know about your own health symptoms or concerns, without your doctor.   Find out every detail about your own health condition and we will create your own Progress Note that you can store, print or download.  The information you submit is safely entered into a secure patient portal that is HIPPA protected and that only you can access, through your own established online password.  Your personal health record and all progress notes that you create about yourself, will look and feel just like the ones at a doctor's office.  The difference is now YOU get to keep your own personal health record and lab results at home, or simply look them up on your mobile device anytime and anywhere!   Enter your own vital signs from your electronic gadgets, such as a pedometer, calorie counter or cell phone blood pressure monitor for easy access and storage wherever you go.  

If are you worried about ever having cancer, diabetes or heart disease, check your health yourself today....without your doctor, and stay one step ahead by taking control of your own Self Health Care Online.  

Please note:  While gathering your self reported health information, we will not diagnose, treat your findings, symptoms or concerns, nor will we become a substitute for a licensed medical provider.  If you feel that you have a medical emergency, call 911.  


How it works: 

Tell Yourself about Yourself.  You will simply CLICK your answers and we will format it into a professional Progress Note that will be safely stored in your personal Patient Portal account online:

  • Health Symptoms or Concerns/Chief Complaint
  • Allergies/Sensitivities
  • Current Medications
  • Surgical History
  • Past Medical History
  • Family History


You will be able to easily enter Your Social History

  • Employment: Student/Unemployed/Employed/Retired/Disability
  • Marital Status: Single/Married/Divorced
  • Children: None/Son/Daughter
  • Exercise: Walking/Running/Hiking/Weight/Lifting/Swimming/Cardio/Biking/Dancing
  • Pets: Dog/Cat/Bird/Horse/Fish/Reptiles
  • Sexual history: Monogamous/Heterosexual/Homosexual/Bisexual/Multiple Partners/High Risk Activity
  • Pregnancies: None/One/Two/Three/Four/Five/Six
  • Alcohol: Never/Weekly/1-2x week/3x week/Daily/Occasionally/History of abuse  
  • Smoking Status: Current every day smoker/Current some day smoker/Former smoker/Never smoker/Smoker, current status
  • Caffeine: None/Rarely/Few times per week/1-2 cups per day/ 3-5 cups per day/ 6 or more cups per day  
  • Use of recreational or street drugs: Never used/Currently use/History of use


Review Your Body Systems

You will be able to CLICK on symptoms or concerns about your:

  • Eyes
  • Ears/Nose/Mouth/Throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Female Genital/Urinary
  • Male Genital/Urinary
  • Musculoskeletal
  • Skin/Hair/Nails


Self-Reported Physical Exam

We ask you the health questions and you examine yourself to complete your own self-reported external physical exam.

Observe your own body with your eyes, a mirror, a selfie or someone's opinion. You will be able to CLICK and answer questions, if you have any of the following:

Appearance: Fever/Chills/Malaise/Fatigue/Night sweats/Recent weight changes/No unintended weight change/Unintended weight gain/Unintended weight loss

Eyes: Blurred vision/Double vision/Photophobia/Visual changes/Discharge/Glaucoma/Itching/Lacrimation/Pain/Redness of eyes/Eyeglasses/Contact lens or eyeglass wearer  

Ears/Nose/Mouth/Throat:  Hearing loss/Ear pain/Tinnitus/Nasal congestion/Nasal discharge/Abnormal sneezing/Bleeding from nose/Postnasal drip/Oral ulcers/Oro-dental problems/Sore throat/Reports Sensation of a lump in the throat/Swollen glands in neck/Ulcerations/Sensation of room spinning

Cardiovascular: Chest pain/Murmur/Palpitation/Claudication/Dyspnea/Orthopnea Leg swelling/Previous EKG    

Respiratory: Cough/Shortness of breath/Chest tightness/Hemoptysis/Asthma/Wheezing 

Gastrointestinal:  Nausea/vomiting/Change in bowel habits/Diarrhea/Constipation/Abdominal pain/Difficulty with swallowing/Blood in stools/Hemorrhoids

Genitourinary:  Blood in urine/Painful urination/Excessive nighttime urination/Urinary frequency/Hesitancy/Urinary urgency/Dribbling/Decreased urine stream/Abnormal discharge/Burning Itching/Pain with sex/History of urinary tract/bladder/kidney infection  

Female Genital/Urinary: Last Menstrual Period/Age at onset of menstruation/Average cycle length/Shortest cycle length/Longest cycle length Number of pregnancies - live births:/Number of abortions/Number of miscarriages/Number of stillbirths/Date of last PAP smear/Painful menstruation/Heavy periods/Menstrual tension/PMS/Hot flashes/night sweats/Recent breast tenderness/lumps/Abnormal vaginal discharge/Prior D and C/C-section/Hysterectomy/Abnormal PAP smear/Pregnancy  

Male Genital/Urinary: Lumps/pain in testicles/Difficulty with erection/ejaculation/Abnormal discharge from penis/Date of last prostate exam

Musculoskeletal: Joint pain/Neck pain/Back pain/Upper extremity pain/Lower extremity pain/Shoulder pain/Numbness/tingling sensations  

Skin/Hair/Nails: Change in skin color/Change in hair/nails/Itching/Rashes/Varicose veins 

Neurological: Weakness/Convulsions/seizures/Migraine headaches/Numbness/Decrease in cognitive skills/Loss of balance/Head injury/Paralysis/Tremors/Psychiatric/Difficulty concentrating/Insomnia/Changes in socializing/Irritability/mood changes/Suicidal thoughts/attempts/Anxiety/Depression/Forgetfulness/Nervousness/Adequate/sound sleep/Previous use of psychotropic medication

Endocrine: Heat/cold intolerance/Excessive urination/Changes in hat/glove size/Nocturia/Glandular/hormonal problem/Excessively dry skin   

Circulation: Hematologic/Lymphatic/Anemia/Easy bruising/bleeding/Night sweats/Tenderness in the nodes of neck/groin area/Slow healing wounds/Past transfusions/Phlebitis/Varicose veins


A summary, or Progress Note of your self reported health information and exam findings will be entered in your personal, password protected, Patient Portal, so that you can clarify, understand and narrow your health symptoms and concerns to print on paper, download or look up anytime online.  We will recommend blood tests that you can order from us online to complete your Healthy Check Up.  The lab results will give you the normal lab value ranges to let you know if they are normal or abnormal.  Lab results will be safely stored online and returned to you via your password protected, personal Healthy Check Up Portal Online.

If you have any abnormal results, we will strongly recommend that you go see a licensed medical provider for diagnosis and treatment.  If you believe that your results are normal, then we congratulate your efforts for choosing to get a Healthy Check Up Online and recommend that you get another check up with us every 3 months to monitor any good or bad changes to your health.

Save time, money and your health and order your Healthy Check Up Online 

Self Health Check Up Questionnaire Form 1

Self Health Questionnaire Form 2

 Self Health Questionnaire Form 3