Pre-Visit Questionnaire Form - Hilltop Family Physicians

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PATIENT NAME: _______________________________________________
PRE-VISIT QUESTIONNAIRE
DOB: _______/_______/_______
DATE: ______/_______/________
Please complete this form before seeing your provider. Your responses will help you receive the best health care possible.
FAMILY HISTORY
Does/did any of your immediate family (mother, father, brother or sister) have the following medical history?
Check all that apply
CONDITION
MOTHER
FATHER
BROTHER
SISTER
Coronary Artery Disease (CAD)
Congestive Heart Failure (CHF)
Hypertension (HTN)
Diabetes (DM)
Cancer
Kidney Disease
Blood clots
Lung disease - please specify
Neurologic Disorder
Depression
Anxiety
Alcohol Abuse
Drug Abuse
Other, please specify:
TOBACCO USE
 Yes
 No
Do you currently smoke cigarettes or use tobacco
:
List Frequency of use
 cigarettes  cigars  e-cigarette  chewing tobacco
products?
 pipe
LIST OF SURGERIES SINCE YOUR LAST VISIT WITH US
TYPE OF SURGERY
WHEN PERFORMED
ALLERGIES
Please list any allergies and the reactions you experience.
TYPE OF ALLERGY
REACTION
Medication Allergies:
Food Allergies:
Environmental Allergies:
m /102016
PLEASE TURN OVER AND COMPLETE OTHER SIDE

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