General Health Questionnaire - Penn Medicine Becker ENT & Allergy

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This field is for validation purposes and should be left unchanged.

Patient Name*

Email*

Date*

Date of Birth*

Medications:

Are you taking any medications, drugs, or pills?*

Yes

If yes, please list name and dosage.*

Allergies:

Do you have any allergic or adverse reactions to any medications or substance?*

Yes

If yes, please list*

Hospitalizations:

Have you been admitted to the hospital during the past five years?*

Yes

If yes, please list name of hospital and year of admission*

Past Medical History:

Please check if you suffer from or have been treated for any of the following medical conditions

Hypertension

Diabetes

Arthritis

Stroke

Other

Untitled*

Past Surgical History:

Please list any major surgeries you have had and the year

Family History:

Please check if any of the following diseases run in your family and indicate which relative(s) (father, mother, brother, sister):

Hypertension

Diabetes

Stroke

Heart Problem

Bleeding Tendencies

Social History:

Do you smoke?*

Yes

If yes, # of packs per day/week.*

Do you drink alcohol?*

Yes

If yes, how many drinks per day/week?*

Do you use any street drugs?*

Yes

If yes, what type?*

Patient’s Name*

I understand the above information is necessary to provide me with surgical/medical care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify my doctor of any change in my health or medications.

Patient/Guardian Signature:*

Date*

I have reviewed all information in the health survey and discussed it with the patient/guardian.

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