General Health Questionnaire Please select the provider you are scheduled to see*Select...Dr. Karen McQuaideDr. Sharon WilliamsDr. Jill MacMillanCaren "CC" SokolowKristina LanzoniDr. Kyle SmithPatient Name*Email* Date* Date Format: MM slash DD slash YYYY Date of Birth* Date Format: MM slash DD slash YYYY Medications:Are you taking any medications, drugs, or pills?*YesNoIf yes, please list name and dosage.*Allergies:Do you have any allergic or adverse reactions to any medications or substance?*YesNoIf yes, please list*Hospitalizations:Have you been admitted to the hospital during the past five years?*YesNoIf 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 yearFamily 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?*YesNoIf yes, # of packs per day/week.*Do you drink alcohol?*YesNoIf yes, how many drinks per day/week?*Do you use any street drugs?*YesNoIf 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* Date Format: MM slash DD slash YYYY I have reviewed all information in the health survey and discussed it with the patient/guardian.By submitting this form I agree to the Terms of UsePhoneThis field is for validation purposes and should be left unchanged.