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    Patient Questionnaire

    Uploaded by

    quillenFB
    This patient questionnaire collects information from a patient visiting the ETSU OB/GYN office, including: 1) Personal information like name, birthday, reason for visit, pharmacy, and primary care physician. 2) Medical history including past and current medical conditions, surgeries, allergies, medications, and lifestyle habits like smoking, drinking, exercise and diet. 3) Immunization history including dates of last tetanus shot, flu vaccine, and other immunizations. 4) Details of preventative cancer screenings like mammograms, colonoscopies and bone density scans based on age.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Patient Questionnaire

    Uploaded by

    quillenFB
    47 views2 pages
    This patient questionnaire collects information from a patient visiting the ETSU OB/GYN office, including: 1) Personal information like name, birthday, reason for visit, pharmacy, and primary care physician. 2) Medical history including past and current medical conditions, surgeries, allergies, medications, and lifestyle habits like smoking, drinking, exercise and diet. 3) Immunization history including dates of last tetanus shot, flu vaccine, and other immunizations. 4) Details of preventative cancer screenings like mammograms, colonoscopies and bone density scans based on age.

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    This patient questionnaire collects information from a patient visiting the ETSU OB/GYN office, including: 1) Personal information like name, birthday, reason for visit, pharmacy, and primary care physician. 2) Medical history including past and current medical conditions, surgeries, allergies, medications, and lifestyle habits like smoking, drinking, exercise and diet. 3) Immunization history including dates of last tetanus shot, flu vaccine, and other immunizations. 4) Details of preventative cancer screenings like mammograms, colonoscopies and bone density scans based on age.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    47 views2 pages

    Patient Questionnaire

    Uploaded by

    quillenFB
    This patient questionnaire collects information from a patient visiting the ETSU OB/GYN office, including: 1) Personal information like name, birthday, reason for visit, pharmacy, and primary care physician. 2) Medical history including past and current medical conditions, surgeries, allergies, medications, and lifestyle habits like smoking, drinking, exercise and diet. 3) Immunization history including dates of last tetanus shot, flu vaccine, and other immunizations. 4) Details of preventative cancer screenings like mammograms, colonoscopies and bone density scans based on age.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Patient Questionnaire !

    Name: ____________________________ Birthday _______________

    Date ____________________

    ETSU OB/GYN 325 N. State of Franklin, Johnson City, TN 37604 (423) 439-7272

    Please complete the questionnaire below:


    Reason for visit today: _________________________________________________________________________________________

    Pharmacy
    Please tell us where you would like your prescriptions sent: ________________________________________________________

    Primary Care Physician


    Who is your primary care doctor? ______________________________________________________________________________

    Past Medical History


    Please list any medical conditions you have:

    Past Surgical History


    Please list any surgeries you have had:

    Allergies
    Do you have any medication or drug allergies?

    Yes No

    If yes, list: _______________________________________________________________________________________________


    Do you have any food or environmental allergies?

    Yes No

    If yes, list: _______________________________________________________________________________________________


    Do you have an allergy to latex or iodine?

    Yes No

    If yes, list: _______________________________________________________________________________________________

    Medications
    Do you use any prescription medications?

    Yes No
    Please flip over and complete the other side

    If yes, list: _______________________________________________________________________________________________


    _________________________________________________________________________________________________________
    _________________________________________________________________________________________________________
    Do you use any over the counter medications? (Goodys Powder, Tylenol, Aspirin, etc.)

    Yes No

    If yes, list: _______________________________________________________________________________________________


    Do you use any supplements or vitamins? (Ginko, Ephedra, Glucosamine, etc.)

    Yes No

    If yes, list: _______________________________________________________________________________________________

    Lifestyle
    Do you wear a seatbelt on a regular basis? Yes No
    How many caffeinated drinks to you consume daily?
    Do you currently smoke?

    0 1 2 3 4 5 6 7+

    Yes No

    If yes, how many packs per day: _______________

    How many alcoholic drinks per week do you consume? 0 1 2 3 4 5 6 7+


    Have you ever used any drugs?

    Currently In the past Never

    If yes, which drugs: __________________________

    Which best describes your nutrition? Good Fair Poor


    Which best describes your weight?

    Underweight Normal weight Overweight Obese

    Do you exercise regularly?

    Yes No

    If yes, how much how often: ______________________________________

    Immunizations
    When was your last tetanus booster?

    Date:____________

    When was your last influenza vaccine?

    Date:____________

    Have you had varicella (chicken pox) or the vaccine?

    Yes No

    Have you been immunized against Hepatitis B?

    Yes No

    Have you ever had the pneumovax vaccine?

    Yes No

    If your age is 26, have you had the HPV vaccine?

    Yes No

    Preventative Medicine
    If your age is 40, when was your last mammogram?

    Date:_____________

    If your age is 50, when was your last colon cancer screen?

    Date:_____________

    If your age is 50, have you ever had a bone scan?

    Date:_____________

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