General Health History Questionnaire Logo
  • General Health History Questionnaire

  • Patient Information

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  • Current and Past Medical History

    Please check the box of any of the following illnesses and medical problems you have or have had and indicate the year when each started. If you are not certain when an illness started, enter an approximate year.
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  • Prior Hospitalization and Surgeries

    Please remember to click on "Save and Add Row" after each input to save your response for the following questions.
  • Medication

    Please remember to click on "Save and Add Row" after each input to save your response for the following questions.
  • Menstrual History

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  • Family History

    If any blood relative has suffered any of the following - please indicate which relative.
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  • Health Risk Factors

  • Other

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  • Should be Empty: