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ETSU OB/GYN Patient Questionnaire

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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80 views2 pages

ETSU OB/GYN Patient Questionnaire

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.

Uploaded by

quillenFB
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

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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