General Health Questionnaire. Understanding your general health will help us to
treat your spine problem. Please complete the following as best as possible. 1.
Conor W. O’Neill, M.D.
General Health Questionnaire
Name:_________________________________________________________ Preferred name:_____________________________________ DOB:__________________________Age:_______________________Height:______________________Weight:______________________ Physician who referred you:_____________________________ Primary care physician:________________________________ 1. Have you EVER been diagnosed with any of the following medical illnesses? Y N Y N Y N Diabetes Blood clots Irritable bowel syndrome High Blood Pressure Gastritis or ulcers Tension headaches Angina Liver Disease Migraines Heart attack Kidney Disease Fibromyalgia Irregular heart beat High cholesterol TMJ syndrome Heart valve problems Thyroid problems Depression Heart Failure Rheumatoid arthritis Anxiety Asthma HIV Panic disorder Emphysema Neuropathy Bipolar Circulation problems Epilepsy/seizures PTSD Stroke or TIA Parkinson’s Chemical Dependency Bleeding problems Interstitial cystitis Alcoholism Cancer Describe:___________________________________________________________________________________________ 2. Do you have any other medical conditions? ____________________________________________________________________ 3. List any surgeries, with approximate dates. Include heart stent, angioplasty, pacemaker or debrillator insertion.______________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 4. List any other hospitalizations, with approximate dates. _____________________________________________________ _________________________________________________________________________________________________________________________ 5. List any medication allergies, including the reaction you have_______________________________________________ _________________________________________________________________________________________________________________________ 6. Have you ever smoked regularly? Yes No. If yes, age you started: __________ Average packs/day: _______________ Still smoking? Yes No If not, age that you quit:______________________________________________ GHv4.0
7. Do you ever drink alcohol? Yes No If yes, how often: _________________________________________________ When you do, how many drinks do you typically have?__________________________________________________________ 8. Do you ever use recreational drugs (e.g. marijuana, cocaine, narcotics)? Yes No If yes, which ones? ____________________________________________________How often?_______________________________________________ 9. Have any close family members (parents, siblings, or children) had any of the following?
Y N Y N Y N Scoliosis Ankylosing spondylitis Alcoholism Back or neck surgery Chronic pain of any kind Chemical Dependency Describe any positive answers __________________________________________________________________________________ 10. Do you CURRENTLY have any of the following symptoms? Y N Y N Y N Recent weight change Chest pain Tremors Fevers Palpitations Dizzy spells Loss of appetite Swelling of feet/ankles Fainting or blackouts Loss of bowel control Difficulty breathing Anxiety/Nervousness Loss of bladder control Chronic cough Low or blue moods Clumsiness Abdominal pain Irritability Balance problems Nausea or vomiting Crying spells Swelling of the joints Constipation Feeling hopeless Joint stiffness Diarrhea Memory loss Eye irritation Black or bloody stools Difficulty concentrating Rashes Burning with urination 4. Please list your medications (prescription and non‐prescription, including vitamins, herbs, supplements) 1. ____________________________________ 6. ____________________________________ 11. __________________________________ 2. ____________________________________ 7. ____________________________________ 12. __________________________________ 3. ____________________________________ 8. ____________________________________ 13. __________________________________ 4. ____________________________________ 9. ____________________________________ 14. __________________________________ 5. ____________________________________ 10. __________________________________ 15. __________________________________