Adult Patient General Health History Questionnaire

1
Name* This field is required.
First Name
MI
Last Name
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2
Date of Birth* This field is required.
MM/DD/YYYY
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3
Gender
Male
Female
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4
E-mail Address* This field is required.
example@example.com
Confirm Email
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5
Current and Past Medical History Part IIf you have or have had any of the following illnesses and medical problems, then please indicate the year when each started. If you are not certain when an illness started, write down an approximate year. Leave blank for the ones that do not apply.
Year
Glaucoma
Emphysema
Deafness or Decreased Hearing
Pneumonia
Thyroid Trouble
Allergies or Hay Fever
Asthma
Tuberculosis
Chronic Bronchitis
Other Lung Problems
Glaucoma
Emphysema
Deafness or Decreased Hearing
Pneumonia
Thyroid Trouble
Allergies or Hay Fever
Asthma
Tuberculosis
Chronic Bronchitis
Other Lung Problems
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
1 of 10
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6
Current and Past Medical History Part IIIf you have or have had any of the following illnesses and medical problems, then please indicate the year when each started. If you are not certain when an illness started, write down an approximate year. Leave blank for the ones that do not apply.
Year
High Blood Pressure
Heart Attack
High Cholesterol
Stomach/Duodenal Ulcer
Diverticulosis
Ulcerative Colitis or Crohn's Dis.
Hepatitis/Jaundice
Liver Trouble
Gallblader Trouble
Hernia
High Blood Pressure
Heart Attack
High Cholesterol
Stomach/Duodenal Ulcer
Diverticulosis
Ulcerative Colitis or Crohn's Dis.
Hepatitis/Jaundice
Liver Trouble
Gallblader Trouble
Hernia
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
1 of 10
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7
Current and Past Medical History Part IIIIf you have or have had any of the following illnesses and medical problems, then please indicate the year when each started. If you are not certain when an illness started, write down an approximate year. Leave blank for the ones that do not apply.
Year
Arthritis
Gout
Cancer
Benign Tumor
Diabetes
Life Threatening Allergic Reaction
Anxiety/Panic Attack
Irritable Bowel Disease
Anemia
Skin Problems
Sexually Transmitted Disease
Arthritis
Gout
Cancer
Benign Tumor
Diabetes
Life Threatening Allergic Reaction
Anxiety/Panic Attack
Irritable Bowel Disease
Anemia
Skin Problems
Sexually Transmitted Disease
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
1 of 11
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8
Current and Past Medical History Part IVIf you have or have had any of the following illnesses and medical problems, then please indicate the year when each started. If you are not certain when an illness started, write down an approximate year. Leave blank for the ones that do not apply.
Year
Breast Lumps or Fibrocystic Dis.
Hemorrhoids
Kidney or Bladder Disease
Kidney Stones
Prostate Problems (Male Only)
Depression
Headaches
Head Injury
Stroke
Convulsions/Seizures
Breast Lumps or Fibrocystic Dis.
Hemorrhoids
Kidney or Bladder Disease
Kidney Stones
Prostate Problems (Male Only)
Depression
Headaches
Head Injury
Stroke
Convulsions/Seizures
Year
Year
Year
Year
Year
Year
Year
Year
Year
Year
1 of 10
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9
If you have or have had cancer, then what type of cancer?Leave blank if it does not apply.
Type of Cancer
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10
If you have or have had a benign tumor, then what type of benign tumor?Leave blank if it does not apply.
Type of Benign Tumor
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11
Prior Operations/Surgeries
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12
Prior Hospitalization other than Surgery
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13
Current Medication Taken
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14
Allergic Reaction to Medication
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15
Menstrual History Part I* This field is required.
Date of Last Period
Regular?
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16
Menstrual History Part II* This field is required.
Number of Pregnancies
Number of Live Children
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17
Menstrual History Part III* This field is required.
Number of Miscarriages
Number of Abortions
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18
Family History Part IIf any blood relative has suffered any of the following, then please indicate which relative (leave blank if none).
Relative
Epilepsy
Migraines
Mental Illness
Glaucoma
Diabetes
Thyroid Disorder
Arthritis
Kidney Disorder
Alcoholism
Epilepsy
Migraines
Mental Illness
Glaucoma
Diabetes
Thyroid Disorder
Arthritis
Kidney Disorder
Alcoholism
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
1 of 9
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19
Family History Part IIIf any blood relative has suffered any of the following, then please indicate which relative (leave blank if none).
Relative
Drug Addiction
Depression
Asthma
Hay Fever
Cancer
Stroke
Hypertension
Heart Disease
Other
Drug Addiction
Depression
Asthma
Hay Fever
Cancer
Stroke
Hypertension
Heart Disease
Other
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
1 of 9
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20
Do you smoke?* This field is required.
YESNO
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21
If so, then:* This field is required.
How many packs per day?
For how many years?
If you've quit, what year?
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22
Do you consume alcohol?* This field is required.
YESNO
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23
If so, then:* This field is required.
What type of alcohol?
How much per week?
How much per day?
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24
Other Health Risk FactorsPlease check all that apply.
Drug Use
HIV Risk Factor (Blood Transfusions, Hemophilia, History of IV Drug Usage, High Risk Sexual Behavior)
Significantly Increased Body Weight
Sedentary Lifestyle
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25
If not currently in a mutually monogamous relationship, do you routinely use condoms?* This field is required.
YESNO
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26
Do you examine your breasts every month?* This field is required.
YESNO
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27
Do you routinely wear a seatbelt?* This field is required.
YESNO
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28
If you are sexually active and are not planning a pregnancy, do you use a form of contraception?* This field is required.
YESNO
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29
Which type of contraception do you use?* This field is required.
Type of Contraception
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30
Signature* This field is required.
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31
Signer's Name* This field is required.
First Name
Last Name
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