General Health History Questionnaire
Patient Information
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Sex (Assigned at Birth)
*
Female
Male
Unknown
E-mail Address
*
Confirmation Email
example@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.
Rows
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
Rows
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
*
/
Month
/
Day
Year
Date
Regular?
*
Yes
No
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.
Rows
Yes
Relative
Epilepsy
Migraines
Mental Illness
Glaucoma
Diabetes
Thyroid Disorder
Arthritis
Kidney Disease
Alcoholism
Rows
Yes
Relative
Drug Addiction
Depression
Asthma
Hay Fever
Cancer
Stroke
Hypertension
Heart Disease
Other
Health Risk Factors
Do you smoke?
*
Yes
No
For how many years?
*
How many packs per day?
*
If you've quit, what year?
*
Do you consume alcohol?
*
Yes
No
What type of alcohol?
*
How many drinks per week?
*
How many drinks per day?
*
Other Health Risk Factors (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
Other
Other
If not currently in a mutually monogamous relationship, do you routinely use condoms?
Yes
No
Do you examine your breasts monthly?
*
Yes
No
Do you routinely wear a seatbelt?
*
Yes
No
If you are sexually active and not planning a pregnancy, do you use a form of contraception?
Yes
No
Which form of contraception do you use?
Signature
*
Signer's Name
*
First Name
Last Name
Submit
Should be Empty: