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General Health Questionnaire
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* Indicates required question
Patient Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
List all medications that you are taking. Include over-the-counter drugs. Include name, strength, frequency, and condition being treated for each medication.
Your answer
Have there been any recent changes to your medications? (change in dosage or new medication.)
*
If yes, please explain nature and date of change. If not, simply write N/A
Your answer
Allergies to medications:
Your answer
Surgical History/Hospitalizations: If applicable, list the year and the reason (condition/illness/surgery.)
Your answer
Social History
Please check appropriate box and give amount.
Do you smoke?
*
Yes
No
If you answered yes to the question above, how many packs do you smoke per day?
*
Less than 1/2
1/2 - 1
1 - 3
3+
N/A
Do you drink alcohol?
*
Yes
No
If you answered yes to the question above, how many drinks per week?
*
1
2 - 5
6 - 10
11+
N/A
Do you drink caffeine products?
*
Yes
No
If you answered yes to the question above, what kind of caffeine products do you drink?
*
Tea
Coffee
Soda
N/A
Required
If you drink caffeine products, how many 8oz cups per day?
*
1 - 2
2 - 3
3 - 4
4+
N/A
Symptom
Review
Please select to indicate if you have had any of the following symptoms or diseases:
Constitutional
Chronic fatigue
Weight loss
Weight gain
Eyes
Blurry vision
Vision loss
Cataracts
Crossed eye/lazy eye
Double vision
Spots before eyes
ENT
Hearing loss
Otalgia
Otorrhea
Ears, itching
Tinnitus
Sound sensitivity
Facial weakness
Facial pain
Vertigo
Difficulty swallowing
Difficulty breathing
Sinus trouble
Cardiovascular
Chest pain
Irregular heart beat
Heart murmur
Heart attack
Any heart trouble
High blood pressure
Low blood pressure
Swelling in legs
Exercise intolerance
Musculoskeletal
Joint pain/stiffness
Neck pain
Neck stiffness
Hip replacement
Knee replacement
Bulging discs of the back or neck
Back/neck surgery
Significant arthritis
Loss of mobility
Fibromyalgia
Gastrointestinal
Decreased appetite
Nausea
Vomiting
Hepatitis
Kidney disease
Neurological
Headaches
Dizziness
Migraines
Tingling
Numbness
Blackouts
Syncope
Tremor
Seizures
Paralysis
Stroke
Memory loss
Confusion
Meningitis
Peripheral neuropathy
Parkinson’s disease
Multiple sclerosis
Psychiatric
Insomnia
Depression
Anxiety
Loss of motivation
Suicidal ideation
Nervous breakdown
Respiratory
Shortness of breath
Tuberculosis
Endocrine
Hypo-thyroidism
Hyper-thyroidism
Increased thirst
Increased hunger
Increase urination
Diabetes
Hormone therapy
Hypoglycemia
Hematologic
Enlarged lymph nodes
Bleeding disorder
Anemia
Previous transfusions
Immunologic
Seasonal allergies
Food allergies
Increased infections
Autoimmune disorders
Sexual transmitted diseases
HIV exposure
HIV positive
Chicken pox
German measles
Mumps
Scarlet fever
Allery to latex
Allergy to adhesive
Have you had or currently have Cancer? If so, add type below
Your answer
Are you currently pregnant or breastfeeding?
*
Pregnant
Breastfeeding
N/A
Family History:
Select the following diseases which are common in your family or have occurred in any family member. Do not include family members by marriage or adoption.
Autoimmune disease
Bleeding disorders
Multiple sclerosis
Dizziness
Diabetes
Hay fever
Hearing loss
Heart disease
High blood pressure
Kidney disease
Meniere’s disease
Migraine
Surgical complications
Parkinson’s disease
Tuberculosis
Vertigo
Stroke
Cancer
Medication History:
Have you ever taken any of the following drugs? Please select all that apply.
Aspirin in large doses
Quinidine (for malaria)
Cisplatin (for cancer)
Streptomycin
Furosemide (Lasix)
Tamoxifen (to prevent breast cancer)
Gentamicin (antibiotic)
Tobramycin (antibiotic)
Kanamycin (antibiotic)
Vancomycin (antibiotic)
Procardia (for blood pressure)
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