(4) Tj Q f H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 238 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL 0.749023 g 0.749023 g (4) Tj endstream endobj 203 0 obj <>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td W f HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. 0 0 10.4683 10.4684 re Patient Name: Last First MI Today’s Date: Reason for Visit: Previous or referring doctor: Patient sex: O M O F DOB: PERSONAL HEALTH HISTORY (PAST MEDICAL HISTORY) Conditions you have had in the past (check all that apply): O … 2.414 2.9774 Td f (4) Tj n endstream endobj 260 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re endstream endobj 216 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q q q �4dG6cq+�^�~ fb`��\�@����������c�9T�'� ,�� endstream endobj 185 0 obj <>/Metadata 5 0 R/PageLabels 180 0 R/Pages 182 0 R/StructTreeRoot 11 0 R/Type/Catalog/ViewerPreferences<>>> endobj 186 0 obj <>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 2/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 187 0 obj <>/Subtype/Form/Type/XObject>>stream H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 268 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W (4) Tj (4) Tj 0 0 10.4683 10.4684 re /ZaDb 6.6672 Tf q SAMPLE LIFESTYLE AND HEALTH-HISTORY QUESTIONNAIRE Continued on the next page. f MEDICAL HISTORY QUESTIONNAIRE TODAY'S DATE: _____ ***Since this is your medical history and it will be used in evaluating your health, it is extremely important that the questions be answered as accurately and completely as possible. 2.414 2.9774 Td Example of Patient Health History Questionnaire Form. 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ET By using this sample, the doctor ensures the patient's better care and treatment. endstream endobj 246 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f q endstream endobj 234 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 1 8.4684 8.4684 re The detailed history about a patient has to be furnished in this document. /Tx BMC q The h ealth history questionnaire is a sheet of questions asking about the patient’s health history. q Q <>>> endstream endobj 210 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream BT 2.414 2.9774 Td ��A)��!6)� 0�x���c�! n BT _____ What other topics would you like to discuss if there is time? Details. f q ET 1 1 8.4684 8.4684 re Patient health history questionnaire is required to be filled by doctors whenever there is a patient coming for the first appointment. BT 1 1 8.4684 8.4684 re endstream endobj 206 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj endstream endobj 282 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream ( ) M ( ) F DOB: _ / _ / PRESENT PULMONARY HEALTH CONCERN(S) Please describe your current pulmonary problem(s) and why you are seeking consultation. f f Q We really want to know you well so we can properly care for you. endstream endobj 202 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf W f n ET endstream endobj 190 0 obj <>/Subtype/Form/Type/XObject>>stream ): M F DOB: Marital status: Single Partnered Married Separated Divorced Widowed Previous or referring doctor: Date of last physical exam: PERSONAL HEALTH HISTORY Childhood illness: Measles Mumps Rubella … endstream endobj 287 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj walking, jogging, weights, swimming, cycling) Describe your diet: (Check one) _____ I eat whatever I want without regard to calories or health content ET endstream endobj 200 0 obj <>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td W W 1 1 8.4683 8.4684 re 0.749023 g ET n 0 0 10.4684 10.4684 re n endstream endobj 212 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj 6.4205 TL EMC (4) Tj q _____ Age of diagnosis: _____ High blood pressure If yes, what is the relation? EMC ET endobj C3h0&�K(� ��Br�ڀZA?B 0.749023 g All information is kept confidential. 0.749023 g n 0.749023 g endstream endobj 198 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 255 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W 1 1 8.4684 8.4684 re Medical History Record PDF template lets you collect the patient's data such as personal information, contact information in an emergency case, general medical history. EMC HEALTH HISTORY QUESTIONNAIRE This form should be completed as fully as possible by client but reviewed by medical or clinical staff. S:\Forms & Handouts\Health history forms\NutritionHealthInformation.docx Revised 2015-10-16 Nutrition and Health Information Questionnaire . <> endstream endobj 261 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj 6.4205 TL ET ET 0 0 10.4684 10.4684 re H�����f�[׽K+���tM�"��PR �0*�;�#g(�Eţ���V��i[�����a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 205 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream EMC 6.4205 TL 6.4205 TL 1 1 8.4684 8.4684 re q All of your answers will be confidential. %PDF-1.6 %���� W f n H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 286 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Hernia, or any condition that may be aggravated by lifting weights or other physical activity q q. 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(4) Tj q /ZaDb 6.6672 Tf Asthma, Diabetes, … Q 0 0 10.4684 10.4684 re endstream endobj 231 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Has anyone in your immediate family been diagnosed with the following? Confidential Health History Questionnaire Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. HEALTH HISTORY QUESTIONNAIRE This questionnaire must be completed before your physical exam or before your provider can sign any activity/camp/sports forms. 2.414 2.9774 Td 2.414 2.9774 Td endstream endobj 266 0 obj <>/Subtype/Form/Type/XObject>>stream (circle one) Yes No Within the past 12 months, have you worried that your food would run out before … Q a. nd . 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Health History Questionnaire Form TYPE OR PRINT CLEARLY Name: Date of Birth: Gender: Male Female Street Address: City/State/ZIP/Country: Your Contact Number(s): Your email: Your Supervisor or Sponsoring Agency & UTH Department/School: Job Title: CONFIDENTIALITY STATEMENT: This form requires that you provide personal health information that isprotected by University policy and State … Pre-Placement Health History Questionnaire | 3 of 5 Confidential ––– ––– 5. 0.749023 g FREE 10+ Sample Health Questionnaire Forms in PDF | MS Word A health questionnaire is usually used to record the medical history of a patient. 4 0 obj ET q (4) Tj BT 1 1 8.4684 8.4684 re endstream endobj 196 0 obj <>/Subtype/Form/Type/XObject>>stream BT endstream endobj 294 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 297 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL BT /ZaDb 6.6672 Tf W BT endstream endobj 269 0 obj <>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td n ET _____ Age of diagnosis: _____ High cholesterol If yes, what is the relation? /ZaDb 6.6672 Tf q ET Q 2.414 2.9774 Td endstream endobj 249 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 199 0 obj <>/Subtype/Form/Type/XObject>>stream Q BT BT 6.4205 TL ET The medical significance of tracking the family genogramcame to light with the developments in medical genetics. The main objective of the health history is to collect the data from the patient so that the guardian of the patient and doctor can create a plan to promote health, address the primary issues, and decreasing the chronic health issues. If there is anything you wish to bring to our attention, which is not included on this form, please note it in the comments section or speak to us about it. n 2.414 2.9774 Td 1 1 8.4683 8.4684 re 0.749023 g endstream endobj 201 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj endobj endstream endobj 191 0 obj <>/Subtype/Form/Type/XObject>>stream n W ��$"F-���S��Tk"M� 1 1 8.4684 8.4684 re BT Q 0 0 10.4683 10.4684 re endstream endobj 225 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W 2.414 2.9774 Td A questionnaire contains a series of questions that the patient would be required to answer. 1 1 8.4684 8.4684 re (circle one) Yes No Type of exercise? 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