General Health Questionnaire

Please select the provider you are scheduled to see*
Patient Name*
Email*
Date*
MM slash DD slash YYYY
Date of Birth*
MM slash DD slash YYYY
Medications:
Are you taking any medications, drugs, or pills?*
- Yes
- No
If yes, please list name and dosage.*
Allergies:
Do you have any allergic or adverse reactions to any medications or substance?*
- Yes
- No
If yes, please list*
Hospitalizations:
Have you been admitted to the hospital during the past five years?*
- Yes
- No
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
- No
If yes, # of packs per day/week.*
Do you drink alcohol?*
- Yes
- No
If yes, how many drinks per day/week?*
Do you use any street drugs?*
- Yes
- No
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*
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 Use
Email

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

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Medications:

Allergies:

Hospitalizations:

Past Medical History:

Past Surgical History:

Family History:

Social History: