General Health Questionnaire

Please complete all entries.

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Patient Name *
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.
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
Allergies to medications:
Surgical History/Hospitalizations: If applicable, list the year and the reason (condition/illness/surgery.)  
Social History
Please check appropriate box and give amount.
Do you smoke? *
If you answered yes to the question above, how many packs do you smoke per day? *
Do you drink alcohol? *
If you answered yes to the question above, how many drinks per week?
 *
Do you drink caffeine products? *
If you answered yes to the question above, what kind of caffeine products do you drink? *
Required
If you drink caffeine products, how many 8oz cups per day? *
Symptom Review 
Please select to indicate if you have had any of the following symptoms or diseases: 
Constitutional
Eyes
ENT
Cardiovascular
Musculoskeletal
Gastrointestinal
Neurological
Psychiatric
Respiratory
Endocrine
Hematologic
Immunologic
Have you had or currently have Cancer? If so, add type below
Are you currently pregnant or breastfeeding? *
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.
Medication History: Have you ever taken any of the following drugs? Please select all that apply.
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