Get Blank Health Questionnaire Form

Completing the Blank Health Questionnaire Form online is an essential step in preparing for your visit to the UCSF Helen Diller Family Comprehensive Cancer Center. This guide provides a clear and supportive approach to help you fill out the form accurately and efficiently.

Follow the steps to complete the questionnaire effectively

1. Click the ‘Get Form’ button to obtain the Blank Health Questionnaire Form and open it for editing.
2. Start by entering your personal information at the top of the form, including your name and date of birth. Make sure this information is present on every page to ensure accuracy.
3. Proceed to the contact information section. Fill in your home address, city, state, ZIP code, and provide your primary and secondary phone numbers. You may also include an email address to ensure effective communication.
4. Indicate your language preference and whether you require an interpreter during appointments. This will assist in providing the best service for your needs.
5. In the family/friend contacts section, specify if you want to allow discussions about your healthcare with family or friends, and fill in their contact information if applicable.
6. Complete the section regarding other physicians involved in your care. Provide names, specialties, and contact information for each physician.
7. Address the allergies section by checking all allergens you may have reacted to and providing details for any medications that have caused allergic reactions.
8. Complete the medical history portion by answering yes or no to various health conditions and listing any past surgeries performed.
9. List your current medications, including prescription drugs, over-the-counter medications, and any supplements you are taking, ensuring to fill in the dosage information.
10. Provide your cancer history if applicable, including any previous diagnoses and treatments you have received.
11. Fill out your family history, lifestyle choices, and any relevant lifestyle information regarding alcohol and tobacco use.
12. For women, complete the specific section regarding female patient history, which includes information about reproductive health and any related medical issues.
13. After completing all sections, review your answers for accuracy. Once verified, you can save your changes, download the form, print it, or share it as needed.

Encourage others to complete their forms online to ensure a smooth process during their medical appointments.