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A pioneer in sinus relief
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Health Questionnaire 2
General Information
Name
DOB
Date
04/24/2024
Drug Allergies
No known drug allergies
Drug
Reaction
Drug
Reaction
Drug
Reaction
Drug
Reaction
Drug
Reaction
Drug
Reaction
Drug
Reaction
Drug
Reaction
Drug
Reaction
Drug
Reaction
Drug
Reaction
Medications
Need to include ALL OTC, prescriptions and supplements.
Currently not on any medications
Name:
How often is it taken?
Dose:
Name:
How often is it taken?
Dose:
Name:
How often is it taken?
Dose:
Name:
How often is it taken?
Dose:
Name:
How often is it taken?
Dose:
Name:
How often is it taken?
Dose:
Name:
How often is it taken?
Dose:
Name:
How often is it taken?
Dose:
Name:
How often is it taken?
Dose:
Name:
How often is it taken?
Dose:
Name:
How often is it taken?
Dose:
Name:
How often is it taken?
Dose:
Surgeries and Hospital Admissions
Never had Any Surgeries
Never been hospitalized
Date
Illness or Operation
Doctor and Location
Date
Illness or Operation
Doctor and Location
Date
Illness or Operation
Doctor and Location
Date
Illness or Operation
Doctor and Location
Date
Illness or Operation
Doctor and Location
Date
Illness or Operation
Doctor and Location
Date
Illness or Operation
Doctor and Location
Date
Illness or Operation
Doctor and Location
Date
Illness or Operation
Doctor and Location
Date
Illness or Operation
Doctor and Location
Date
Illness or Operation
Doctor and Location
Immunizations
Date
Location
Doctor
HIB
Date
Location
Doctor
Influenza
Date
Location
Doctor
Pneumovax
Date
Location
Doctor
Small Pox
Date
Location
Doctor
Chicken Pox
Date
Location
Doctor
Tetanus
Date
Location
Doctor
H1N1
Date
Location
Doctor
HPV
Date
Location
Doctor
MMR
Date
Location
Doctor
Implanted devices
Does the patient have any implanted device(s)?
Yes
No
Does the patient have a card for the device(s)?
Yes
No
Type of device(s)?
Cigarettes
If current or former smoker please answer all questions.
Smoker?
Current
Former
Never
If you are a current smoker:
Number of Packs Per Day
If you are a current or former smoker:
Years smoked
If you are a former smoker:
When did you quit
Number of packs per day before quitting
Alcohol
Do you drink alcohol?
Yes
No
Frequency
Socially
Minimally
Infrequently
Frequently
How many drinks/week
Beer
Liquor
Wine
Drug Use
Do you use Drugs?
Yes
No
Type
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footprint
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luggage
