Greensboro Medical Associates Health Information Questionnaire

Greensboro Medical Associates Health Information Questionnaire - Internal and Family Medicine

Please complete all sections to help us provide you with the best possible care. Your information is confidential.
Name*

First NameLast Name
Age*
Today's Date*

MonthDayYear
Date
Place of Birth
Date of Birth*

MonthDayYear
Date
Other Doctors You See
Marital Status
Spouse Alive / Age
Spouse Deceased / Age
Spouse Major Illness
Employment Status
Current or Former Occupation
Main Reason for Visit*
Education (Years)
Religion
Regular Exercise (type)
Regular Exercise Level
Hobbies / Sports
Have you used IV drugs?
Tobacco - Type
Tobacco - How much
Tobacco - Quit (When)
Alcohol - Type
Alcohol - How much
Alcohol - Days per week
Alcohol - Quit?
Medications (List all medications, eye drops, vitamins, including over-the-counter medications and supplements - include dose and frequency)
Preferred Pharmacy
Drug or Food Allergies + Reaction
Previous Surgeries - Operations / Date / Hospital / Surgeon
Previous Injuries
Previous Hospital Stays
EMERGENCY CONTACT
Emergency Contact Name*
Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Family Medical History - (Relationship, Age, Health, Age at Death, Cause)
Other medical conditions in relatives
CancerHeart problemsLung problemsGoiterLeukemiaStrokeInfectionDiabetesSeizuresNervous breakdownStomach ulcersColitisBad headachesJaundiceKidney Disease
Other (past personal history)
Please List The Date of Your Last Below

If you have never had one of the below, please leave blank.
Last Colonoscopy
Last Tetanus Vaccine
Last Mamogram
Last Pneumonia Vaccine
Last Eye Exam
Last Aortic Aneurysm Screen
Last Pap Smear
Last Hepatitis B Vaccine
Last Bone Density
If Patient Is Filling Out The Form
Patient's Signature*
Patient Mobile Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date (Patient's Signature)*

MonthDayYear
Date
If Someone Other Than The Patient Is Filling Out The Form
If Not The Patient, Signature Of Person Filling Out Form
Relationship To The Patient
Date (person filling out form)

MonthDayYear
Date
Should be Empty:

Greensboro Medical Associates Health Information Questionnaire - Internal and Family Medicine

EMERGENCY CONTACT

Please List The Date of Your Last Below

If Patient Is Filling Out The Form

If Someone Other Than The Patient Is Filling Out The Form