Medical History - New Patient Questionnaire Page 2
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6. Have you ever gone to an emergency room for treatment in the last
year?
Yes
No
How many times in the past year?
List the reason and when you made each ER visit.
Reason:
Month:
Year:
Reason:
Month:
Year:
Reason:
Month:
Year:
7. Have you ever stayed in the hospital overnight during the past year?
Yes
No
How many times in the past year?
List the reason and when you stayed overnight.
Reason:
Month:
Year:
Reason:
Month:
Year:
Reason:
Month:
Year:
8. Have you had surgery?
Yes
No
List the type of surgery or reason for surgery including dates.
Reason:
Month:
Year:
Reason:
Month:
Year:
Reason:
Month:
Year:
9. List any allergies you have to food or medications.
Tip: Only 5 lines available, so summarize.
10. Have you ever had an anaphylactic reaction (turning red, overall swelling, difficulty
breathing)?
Yes
No
11. Do you smoke?
Yes
No
Select which products you use, how much, and number of years used.
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Parent category: Life