General Appointment Questionnaire

Name*
First Last
Gender*
Date of Birth*
Date Format: MM slash DD slash YYYY
Height*
Weight*
Family Doctor*
Referring Doctor*
Reason for Visit*
Preferred Contact number*
Health History:
Please note any health conditions under the following categories
Heart*
Lung*
Neurological/Brain*
Kidney*
Liver*
Cancer*
History of Hepatitis or HIV?*
Bleeding problems or Blood Clots*
Have you ever been diagnosed with:
Please answer Yes or No
High blood pressure?*
Diabetes?*
High Cholesterol?*
Surgical History:
What surgeries have you had?*
Medications*
Drug Allergies*
Family History:
Please state relationship and age of diagnosis if known
Colon or rectal cancer*
Stomach Cancer*
Breast Cancer*
Crohns disease or Ulcerative Colitis*
Social History:
Do you smoke?*
How much per day?*
Do you drink alcohol?*
How many drinks/week?*
Occupation*

Important Office Information