General Health History Questionnaire

General Health History Questionnaire
Patient Information
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Sex (Assigned at Birth)*

FemaleMaleUnknown
E-mail Address*

Confirmation Emailexample@example.com
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.

	Yes	Year
Allergies or Hay Fever
Anemia
Anxiety/Panic Attack
Arthritis
Asthma
Benign Tumor*
Bleeding Tendency
Breast Lumps or Fibrocystic Dis.
Cancer*
Chronic Bronchitis
Convulsions, Seizures
Deafness or Decreased Hearing
Depression
Diabetes
Diverticulosis
Emphysema
Gallbladder Trouble
Glaucoma
Gout
Headaches
Head Injury

	Yes	Year
Heart Attack
Hemorrhoids
Hepatitis/Jaundice
Hernia
High Blood Pressure
High Cholesterol
Irritable Bowel Syndrome
Kidney or Bladder Disease
Kidney Stones
Life Threatening Allergies
Liver Trouble
Lung Problems
Pneumonia
Prostate Problems (male only)
Sexually Transmitted Disease
Skin Problems
Stroke
Thyroid trouble
Tuberculosis
Ulcerative Colitis or Chron's Disease

*If you have or have had cancer, please indicate the type of cancer:
Leave blank if it does not apply.
*If you have or have had a benign tumor, please indicate the type of benign tumor:
Leave blank if it does not apply.
Prior Hospitalization and Surgeries

Please remember to click on "Save and Add Row" after each input to save your response for the following questions.
Prior Operations/Surgeries
Hospitalization (Other than surgery)
Medication

Please remember to click on "Save and Add Row" after each input to save your response for the following questions.
Current Medication Taken
Allergic Reaction to Medication
Menstrual History
Date of Last Period*

MonthDayYear
Date
Regular?*

YesNo
Number of Pregnancies*
Number of Live Children*
Number of Miscarriages*
Number of Abortions*
Family History

If any blood relative has suffered any of the following - please indicate which relative.

Health Risk Factors
Do you smoke?*

YesNo
For how many years?*
How many packs per day?*
If you've quit, what year?*
Do you consume alcohol?*

YesNo
What type of alcohol?*
How many drinks per week?*
How many drinks per day?*
Other Health Risk Factors (Check all that apply)

Drug UseHIV Risk Factor (Blood Transfusions, Hemophilia, History of IV Drug Usage, High Risk Sexual Behavior)Significantly Increased Body WeightSedentary LifestyleOther
Other
If not currently in a mutually monogamous relationship, do you routinely use condoms?

YesNo
Do you examine your breasts monthly?*

YesNo
Do you routinely wear a seatbelt?*

YesNo
If you are sexually active and not planning a pregnancy, do you use a form of contraception?

YesNo
Which form of contraception do you use?
Signature*

Clear
Signer's Name*

First NameLast Name
Should be Empty:

Patient Information