health history questionnaire pdf

6.4205 TL W 2.414 2.9774 Td 0.749023 g /ZaDb 6.6672 Tf Health and Lifestyle Questionnaire. n H��f�[׽K+��tM�"��PR �0*�;�#g(�Eţ��V��i[��a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 229 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q 0.749023 g (circle one) Yes No Within the past 12 months, have you worried that your food would run out before â¦ W W W 6.4205 TL 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 â¦ Q /ZaDb 6.6672 Tf W W BT ET f endstream endobj 242 0 obj <>/Subtype/Form/Type/XObject>>stream 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. 0 0 10.4683 10.4684 re endstream endobj 254 0 obj <>/Subtype/Form/Type/XObject>>stream q endstream endobj 240 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream _____ What other topics would you like to discuss if there is time? 184 0 obj <> endobj 319 0 obj <>/Filter/FlateDecode/ID[<6B891314069B4CCCBD832608282591E1>]/Index[184 207]/Info 183 0 R/Length 188/Prev 101030/Root 185 0 R/Size 391/Type/XRef/W[1 3 1]>>stream 6.4205 TL Patient health history questionnaire is required to be filled by doctors whenever there is a patient coming for the first appointment. 2.414 2.9774 Td EMC n y��-��T�^9�� -_?��g�usw�N�q�ަ��*6��r W f Name: DOB: Height: Weight: Hospital Used: Reason for Visit Today: ALLERGIES: List a. ll . ET ET The more detail you provide, the more we can tailor our time together to meet your individual nutrition needs and goals. /ZaDb 6.6672 Tf %PDF-1.6 %�� /Tx BMC n BT endstream endobj 192 0 obj <>/Subtype/Form/Type/XObject>>stream Q EMC /ZaDb 6.6672 Tf EMC Patient Name: Last First MI Todayâs 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 â¦ W known allergies No Known Dru. 2.414 2.9774 Td q BT /ZaDb 6.6672 Tf n H�E��}�+��N��M+��[�J�A��x��W�� o�U�.x-ό}��w�DTcN0��4ju�7�1O��1q�W� )�y endstream endobj 262 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td Health History . q 2.414 2.9774 Td f Q ET endstream endobj 275 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g endstream endobj 213 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream n f _____ Age of diagnosis: _____ High blood pressure If yes, what is the relation? BT 6.4205 TL 2 0 obj Q endstream endobj 293 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 225 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Asthma, Diabetes, â¦ 0 0 10.4684 10.4684 re 1 1 8.4683 8.4684 re h�bbd```b``��0� (4) Tj <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 0.749023 g q 0.749023 g [Ƭ��Qw��]|{T]�x|4:Yw��+��ş��N��nt��{��xes��g��h��%��Y��'k��:h�/5 5��ts|4\ܚ��5{��j�w�0��ߎJ]�^Y� ��Z�N��k7�0%M��L�o��Nc�oo}�]]u#�)Jk�)^CcU�kH�U��޸2*�x�ǡ��CӘ�L�?�Nl�0�3Kw��T�v��0�� ,H��?fݘ�p�>�o͕˷��ϭ �� T]�=��ˣ�A��[{��櫣��kw��u��m�~�#�]W�3�;��u��V݀WCWC�2��(�y� ��x��ß 0.749023 g Q Name (Last, First M.I. 2.414 2.9774 Td endstream endobj 297 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q ET endstream endobj 207 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re q Q Q f W ��P+((¥FM�6 6.4205 TL W (4) Tj ET By using this sample, the doctor ensures the patient's better care and treatment. 6.4205 TL (4) Tj Details. /ZaDb 6.6672 Tf 2.414 2.9774 Td :��3hR�D�A��$R�TH"c� ��q��c�"&4�Kib�A�. q 1 1 8.4684 8.4684 re 0.749023 g EMC BT endstream endobj 264 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream ET 2.414 2.9774 Td /Tx BMC q By using this sample, the doctor ensures the patient's better care and treatment. H��f�[׽K+��tM�"��PR �0*�;�#g(�Eţ��V��i[��a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 241 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q pages. W W (4) Tj endstream endobj 191 0 obj <>/Subtype/Form/Type/XObject>>stream %�� It is long because it is comprehensive. Has anyone in your immediate family been diagnosed with the following? ET (4) Tj endstream endobj 237 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream n 2.414 2.9774 Td Please fill out this form to the best of your ability. /ZaDb 6.6672 Tf endstream endobj 197 0 obj <>/Subtype/Form/Type/XObject>>stream W walking, jogging, weights, swimming, cycling) Describe your diet: (Check one) _____ I eat whatever I want without regard to calories or health content (4) Tj /Tx BMC endstream endobj 278 0 obj <>/Subtype/Form/Type/XObject>>stream File Format. f Pediatric Health History Questionnaire Template Name (Last, First, M.I. 4 0 obj Age requirements may apply for some products and services offered. 1 1 8.4683 8.4684 re Plus, receive special offers and a birthday gift! endobj endstream endobj 204 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q ET HEALTH HISTORY QUESTIONNAIRE This form should be completed as fully as possible by client but reviewed by medical or clinical staff. EMC n BT 2.414 2.9774 Td 1 1 8.4684 8.4684 re /Tx BMC q 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 endstream endobj 255 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q ET (4) Tj 2.414 2.9774 Td endstream endobj 269 0 obj <>/Subtype/Form/Type/XObject>>stream ET QUESTIONNAIRE. 1 1 8.4684 8.4684 re It is concerned with disorders that can be transmitted from the parent to offspring and succeeding generation. Q Over the Counter (OTC) medications, including Vitamins or Herbal MEDICATIONS: Social History Marital Status: _____ Occupation: _____ Smoking Status: Never Former When did you quit? n endstream endobj 272 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 231 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf 1 1 8.4683 8.4684 re BT n 2.414 2.9774 Td 0 0 10.4684 10.4684 re 2.414 2.9774 Td endstream endobj 196 0 obj <>/Subtype/Form/Type/XObject>>stream W /ZaDb 6.6672 Tf (4) Tj Questionnaire . H�E��}�+��N��M+��[�J�A��x��W�� o�U�.x-ό}��w�DTcN0��4ju�7�1O��1q�W� )�y endstream endobj 277 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 267 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0.749023 g W endstream endobj 203 0 obj <>/Subtype/Form/Type/XObject>>stream HEALTH HISTORY QUESTIONNAIRE DATE: / / NAME:(Last, First, M.I.) 1 1 8.4684 8.4684 re �m�j98�v�77�w��`g0G��5)�33K?��Y�D��T �p��^ʮ��j�?��e\5��hFsiX�kuWĭ/�W�J�ӝ�ld��Hq҄��hBq�a?�ћ��ӷ��]��i�T.�۩��`!�p��E�|GOn&�xZ�'�C��"��B�Y$��u;u쇱R�=�lov�8��Ҳݯ1��m�=o.�^.-M��6�e��k�u�0��Z�lN��$�g+��ޜ��[�KJ�{�� t}r �ۣ�]��o��vb��`n��6��fJ�7��g��p#��j�*��MgoE�V-J�Uvb��T�D��ߘ�o��S��n!m:�G��.��Eٛ�ʣU�M��~��P��&��I�S�옦vX�l۪k[8O��. q BT 1 1 8.4684 8.4684 re h��[�r�8�~��f��A�j+W��L|��cg�ٔ늖(�g�ԒT&ާ�G�n ��"3Yk\*��׍��aD��H#�� 1 1 8.4683 8.4684 re EMC 1 1 8.4684 8.4684 re <> endstream endobj 285 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream BT H�E��}�+��N��M+��[�J�A��x��W�� o�U�.x-ό}��w�DTcN0��4ju�7�1O��1q�W� )�y endstream endobj 283 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 249 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream BT 2.414 2.9774 Td /ZaDb 6.6672 Tf 6.4205 TL 0 0 10.4684 10.4684 re EMC 0 0 10.4684 10.4684 re 0.749023 g 6.4205 TL /Tx BMC Please fill in all . n 2.414 2.9774 Td 1 1 8.4683 8.4684 re /Tx BMC /ZaDb 6.6672 Tf (4) Tj endstream endobj 246 0 obj <>/ProcSet[/PDF/Text]>>/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 256 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td 0.749023 g 0 0 10.4684 10.4684 re H�E��}�+��N��M+��[�J�A��x��W�� o�U�.x-ό}��w�DTcN0��4ju�7�1O��1q�W� )�y endstream endobj 250 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 224 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 195 0 obj <>/Subtype/Form/Type/XObject>>stream f H��f�[׽K+��tM�"��PR �0*�;�#g(�Eţ��V��i[��a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 217 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0 0 10.4683 10.4684 re W 6.4205 TL HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. HEALTH HISTORY QUESTIONNAIRE. 0 0 10.4683 10.4684 re f H��f�[׽K+��tM�"��PR �0*�;�#g(�Eţ��V��i[��a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 235 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL /ZaDb 6.6672 Tf H��f�[׽K+��tM�"��PR �0*�;�#g(�Eţ��V��i[��a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 220 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream H��f�[׽K+��tM�"��PR �0*�;�#g(�Eţ��V��i[��a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 214 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 215 0 obj <>/Subtype/Form/Type/XObject>>stream f ET 0.749023 g /ZaDb 6.6672 Tf f BT Q EMC endstream endobj 276 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 279 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream n n /ZaDb 6.6672 Tf H��f�[׽K+��tM�"��PR �0*�;�#g(�Eţ��V��i[��a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 208 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 239 0 obj <>/Subtype/Form/Type/XObject>>stream �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 HEALTH HISTORY QUESTIONNAIRE Name _____ Date of Birth _____ Date Completed _____ What is the major focus of your visit? The h ealth history questionnaire is a sheet of questions asking about the patientâs health history. endstream endobj 218 0 obj <>/Subtype/Form/Type/XObject>>stream ET f 1 1 8.4684 8.4684 re 0 0 10.4683 10.4684 re q ��$"F-��S��Tk"M� 1 1 8.4684 8.4684 re 0 0 10.4684 10.4684 re 2.414 2.9774 Td Q endstream endobj 248 0 obj <>/Subtype/Form/Type/XObject>>stream f MeltSpa by Hershey Health History Form Guest Name: _____ Date: _____ Address: _____ City: _____ State: _____ Phone: _____ Email: _____ Date of Birth: _____ Sign Me Up For Spa Email: Be the first to know about seasonal treatments and packages. /Tx BMC BT Health Questionnaire - Nutrition Assessment - Page 2 Client Insurance Form We are in-network providers of Blue Cross Blue Shield of Minnesota. _____ â¦ q 1 0 obj Heart disease If yes, what is the relation? _____ Do you feel safe at home? (4) Tj n EMC 6.4205 TL endstream endobj 190 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 232 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL 0.749023 g EMC 0 0 10.4683 10.4684 re ET 0 0 10.4683 10.4684 re f H��f�[׽K+��tM�"��PR �0*�;�#g(�Eţ��V��i[��a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 226 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream From the questionnaire the doctor gets the idea from where to start the treatment and for this, the template of the pediatric questionnaire should be downloaded 2. endstream endobj 188 0 obj <>/Subtype/Form/Type/XObject>>stream q 0 0 10.4684 10.4684 re Name (Last, First, M.I.) Pre-Placement Health History Questionnaire | 3 of 5 Confidential âââ âââ 5. 2.414 2.9774 Td /Tx BMC A2�D��dW �Y��Y�V �WA$�B�C��teN ��0��a"�.��!Z�d��~oD�01�I~0yL��ɲ�v�\'A$��H�d��6?,;l�� V��g��Y� ��30��}7@� �aF� endstream endobj startxref 0 %%EOF 390 0 obj <>stream If you have questions, please ask. q q 0.749023 g endstream endobj 281 0 obj <>/Subtype/Form/Type/XObject>>stream Download. endstream endobj 263 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf 2.414 2.9774 Td 2.414 2.9774 Td n Q f q endstream endobj 261 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf ET Q q 6.4205 TL Q q Q ET BT 6.4205 TL BT endstream endobj 210 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 233 0 obj <>/Subtype/Form/Type/XObject>>stream 0 0 10.4683 10.4684 re 0 0 10.4683 10.4684 re BT BT 2.414 2.9774 Td Name (Last, First, M.I. 1 1 8.4684 8.4684 re Q 0 0 10.4683 10.4684 re Explain all âYESâ responses in the space provided below. 1 1 8.4684 8.4684 re BT Health History Questionnaire - New Patient -Gastroenterology MRN: NAME: BIRTHDATE: CSN: FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART. 3 0 obj endstream endobj 260 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj f 1 1 8.4683 8.4684 re 0.749023 g Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. PDF | The development and standardization of the Women's Health Questionnaire (WHQ) is described. endstream endobj 287 0 obj <>/Subtype/Form/Type/XObject>>stream n BT 6.4205 TL 2.414 2.9774 Td 2.414 2.9774 Td /Tx BMC endstream endobj 234 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 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. All of your answers will be confidential. 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 0 0 10.4684 10.4684 re endstream endobj 258 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream ET The medical significance of tracking the family genogramcame to light with the developments in medical genetics. Because these diseases are at the geneâ¦ W 0.749023 g _____ What symptoms are you having? 0.749023 g q endstream endobj 194 0 obj <>/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. A questionnaire contains a series of questions that the patient would be required to answer. 0 0 10.4683 10.4684 re Q ): M F . 6.4205 TL 6.4205 TL 1 1 8.4684 8.4684 re 0.749023 g q q Example of Patient Health History Questionnaire Form. f Hernia, or any condition that may be aggravated by lifting weights or other physical activity q q. HEALTH-HISTORY . (4) Tj 0.749023 g ET The patient history, allergies and other information are presented in different sections. n SAMPLE LIFESTYLE AND HEALTH-HISTORY QUESTIONNAIRE Continued on the next page. /ZaDb 6.6672 Tf Q EMC H�E��}�+��N��M+��[�J�A��x��W�� o�U�.x-ό}��w�DTcN0��4ju�7�1O��1q�W� )�y endstream endobj 244 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj n 2.414 2.9774 Td ): 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 â¦ /Tx BMC 2.414 2.9774 Td 2.414 2.9774 Td f �1�P0$�!��$�#��$8 #[�Z.�� n 0.749023 g 6.4205 TL W f The detailed history about a patient has to be furnished in this document. n 0 0 10.4683 10.4684 re If you are a current patient there is a shorter update form you ca n use. Confidential Health History Questionnaire Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. endstream endobj 236 0 obj <>/Subtype/Form/Type/XObject>>stream

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