Health Questionnaire

Health Questionnaire
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
What is the reason for today's visit?
Current Medications: Please include strength, dosage, and how long you have been on this medications.
MEDICAL HISTORY
Please list any drug or food allergies:
Have you been diagnosed with any of the following conditions? If so, please list the providers name in the provided space below.

ArthritisAsthmaCancerCataracts/GlaucomaDepression/AnxietyDiabetes/SugarBlod ClotsBleeding DisorderColorectal Cancer ScreeningCoronary Artery DiseaseEczemaEmphysema/COPDGastrointestinal DisordersHeart DiseaseHigh Blood PressureHigh CholesterolHIV/STDIschemic Vascular DiseaseKidney StonesLiver DiseaseNeck/Back ProblemsSkin DisordersSeizuresStrokeThyroid DisorderTuberculosisUrinary Tract Infections
Please list specialist's name and condition you are currently seeing them for.

Family History (blood realtives)

	Father	Mother	Brother	Sister	Son	Daughter
Please mark box if deceased
Asthma
Bleeding Disorder
Cancer
COPD
Depression
Diabetes/Sugar
Drug/Alcohol Abuse
Heart Attack
High Blood Pressure
Seizures
Stroke

List any hospitalizations or trips to the emergency room in the past two (2) years.
List all surgical procedures and the year they were performed.
SOCIAL HISTORY
Do you currently use any of the following?

Smoke cigarettes/cigarsVapeChew Tobacco
How much a day?
How many years?
Would you like help quitting?

YesNo
Are you a former smoker/smokeless tobacco user?

YesNo
How long has it been since you last used tobacco?
If you are under the age of 18, please skip the following sections. Scroll to the bottom and click "Submit" Patients 18 and over please complete the following questions and then click "Submit".
CAGE-AID Questionnaire

If you are 18 years old and above, please complete this section. Skip this section if you are under 18.
Do you drink alcohol?

YesNo
If so, how much and how often?
Do you use illegal drugs?

YesNo
If yes, please answer the following questIons.

When thinking about drug use, include illegal drug use and the use of prescription drug use other than prescribed.
Have you ever thought you ought to cut down on your drinking?

YesNo
Have people annoyed you by criticizing your drinking or drug use?

YesNo
Have you ever felt bad or guilty about your drinking or drug use?

YesNo
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?

YesNo
PC-PTSD-5
Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:
- a serious accident or fire
- a physical or sexual assault or abuse
- an earthquike or flood
- a war
- seeing someone be killed or seriously injured
- having a loved one die through homicide or suicide
Have you ever experienced this kind of event?

YesNo
If yes, please answer the following questions.

In the past month, have you experienced any of the following?
Had nightmares about event(s) or thought about the event(s) when you did not want to?

YesNo
Tried hard not to think about the event(s) or went our of your way to avoid situations that reminded you of the event(s)?

YesNo
Been constantly on guard, watchful, or easily startled?

YesNo
Felt numb or detached from people, activities, or your surroundings?

YesNo
Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

YesNo
GAD-7

Over the last two weeks, how often have you been bothered by any of the following problems?

	Not at all	Several days	More than half days	Nearly everyday
Feeling nervous, anxious, or on edge
Not bein able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

If you checked any of the previous problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? (choose one)

Not difficult at allSomewhat difficultVery difficultExtremely difficult
Should be Empty:

Health Questionnaire

MEDICAL HISTORY

SOCIAL HISTORY

If you are under the age of 18, please skip the following sections. Scroll to the bottom and click "Submit" Patients 18 and over please complete the following questions and then click "Submit".

CAGE-AID Questionnaire

If yes, please answer the following questIons.

PC-PTSD-5

GAD-7