General Health Questionnaire - California Spine Diagnostics

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. __________________________________