/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream n 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 endstream endobj 222 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 279 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0.749023 g q 1 1 8.4683 8.4684 re EMC H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 280 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td (4) Tj DOB; status: Single Partnered Married Separated Divorced Widowed Previous or referring doctor: Date of last physical exam PERSONAL HEALTH HISTORY Childhood illness: Meas|p Mumps Rubella Chickenpox … /ZaDb 6.6672 Tf 6.4205 TL W BT 1 1 8.4683 8.4684 re �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 2.414 2.9774 Td ET Health History Questionnaire Patient Name:_____ DOB: _____ Main reason for today’s visit: _____ Other concerns:_____ ... History of Falls: (last 3 months) No falls 1-2 3 or more Do you exercise? /ZaDb 6.6672 Tf 6.4205 TL /Tx BMC 1 1 8.4683 8.4684 re q PDF | The development and standardization of the Women's Health Questionnaire (WHQ) is described. Please fill out this form to the best of your ability. (4) Tj W ET 6.4205 TL BT q 2.414 2.9774 Td n endstream endobj 251 0 obj <>/Subtype/Form/Type/XObject>>stream Q Name (Last, First, M.I. 1 1 8.4683 8.4684 re 0 0 10.4684 10.4684 re W endstream endobj 245 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re q BT n 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 213 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0 0 10.4683 10.4684 re By using this sample, the doctor ensures the patient's better care and treatment. /ZaDb 6.6672 Tf q q 2.414 2.9774 Td W H�����f�[׽K+���tM�"��PR �0*�;�#g(�Eţ���V��i[�����a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 253 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream _____ What other topics would you like to discuss if there is time? H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 274 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream h��[�r�8�~���f��A�j+W��L|���cg�ٔ늖(�g�ԒT&ާ�G�n ���"3Yk\*����׍���aD��H#��� �� h�bbd```b``������0� endstream endobj 236 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf H�����f�[׽K+���tM�"��PR �0*�;�#g(�Eţ���V��i[�����a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 265 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream [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 endstream endobj 207 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0.749023 g (4) Tj Details. f endstream endobj 294 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f W 2.414 2.9774 Td ET q endstream endobj 199 0 obj <>/Subtype/Form/Type/XObject>>stream 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. 2.414 2.9774 Td 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. W 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 … <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> All of your answers will be confidential. W 2.414 2.9774 Td Social History Do you exercise regularly? 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 /Tx BMC q /ZaDb 6.6672 Tf q The field deals with the role of genes and heredity in the health and well-being of a person. Q n n ET /ZaDb 6.6672 Tf 0.749023 g The h ealth history questionnaire is a sheet of questions asking about the patient’s health history. 2.414 2.9774 Td 0 0 10.4683 10.4684 re EMC 1 1 8.4684 8.4684 re /ZaDb 6.6672 Tf In the questionnaire the health detail of the child is given and need to mention if the child has any complication and symptom. endstream endobj 270 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0 0 10.4684 10.4684 re 6.4205 TL 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 2.414 2.9774 Td ET /ZaDb 6.6672 Tf 1 1 8.4684 8.4684 re 2.414 2.9774 Td 0 0 10.4684 10.4684 re endstream endobj 258 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL /Tx BMC Q 0.749023 g n /ZaDb 6.6672 Tf Age Have you had any of the following health problems? 0 0 10.4684 10.4684 re endstream endobj 196 0 obj <>/Subtype/Form/Type/XObject>>stream 6.4205 TL endstream endobj 203 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g Name (Last, First M.I. 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 0.749023 g QUESTIONNAIRE. 2.414 2.9774 Td endstream endobj 285 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q BT ET ET 0 0 10.4684 10.4684 re 1 1 8.4684 8.4684 re 6.4205 TL 2.414 2.9774 Td Pre-Placement Health History Questionnaire | 3 of 5 Confidential ––– ––– 5. 6.4205 TL (4) Tj 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 … n endstream endobj 191 0 obj <>/Subtype/Form/Type/XObject>>stream W n endstream endobj 260 0 obj <>/Subtype/Form/Type/XObject>>stream f f six . /ZaDb 6.6672 Tf BT All information is kept confidential. 6.4205 TL Family History 1. endobj 1 1 8.4684 8.4684 re n 0 0 10.4684 10.4684 re BT BT 0 0 10.4683 10.4684 re q f 2.414 2.9774 Td endstream endobj 261 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj Name: DOB: Height: Weight: Hospital Used: Reason for Visit Today: ALLERGIES: List a. ll . Q f endstream endobj 227 0 obj <>/Subtype/Form/Type/XObject>>stream f 1 1 8.4683 8.4684 re 0.749023 g BT H�����f�[׽K+���tM�"��PR �0*�;�#g(�Eţ���V��i[�����a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 271 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL endstream endobj 225 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 0 obj The more detail you provide, the more we can tailor our time together to meet your individual nutrition needs and goals. endstream endobj 255 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td endstream endobj 192 0 obj <>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td All questions contained in this questionnaire are strictly confidential and will become part of your medical record. 0.749023 g 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 endstream endobj 234 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q 6.4205 TL (4) Tj W BT Pediatric Health History Questionnaire Template endstream endobj 204 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q 6.4205 TL :���3hR�D�A��$R�TH"c� ��q��c�"&4�Kib�A�. /ZaDb 6.6672 Tf endobj Name (Last, First, M.I.) n The detailed history about a patient has to be furnished in this document. 1 1 8.4683 8.4684 re Age requirements may apply for some products and services offered. 2.414 2.9774 Td f q 0.749023 g q EMC 2.414 2.9774 Td %PDF-1.5 It is concerned with disorders that can be transmitted from the parent to offspring and succeeding generation. 0.749023 g f q 1 1 8.4684 8.4684 re H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 244 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q (4) Tj n HEALTH HISTORY QUESTIONNAIRE (HHQ) PLEASE PRINT, COMPLETE AND MAIL THIS FORM TO: Annette Biggs Associate Director UCCS Recreation Center 1420 Austin Bluffs Parkway Colorado Spring, CO 80918 Today’s date: _____ Date of birth: _____ /ZaDb 6.6672 Tf �m�j98�v�77�w���`g0G��5)�33K?��Y�D��T �p��������^ʮ��j�?���e\5�����hFsiX�kuWĭ/�W�J�ӝ�ld���Hq҄���hBq�a?�ћ��ӷ����]���i�T.�۩��`!�p��E�|GOn&�xZ�'�C���"��B�Y$����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 Surgical History Surgery Date Health Maintenance History Test Date Results Blood Tests Bone Density Scan Colonoscopy Eye Exam Mammogram PAP Smear Physical Functional Levels (Katz ADL) – Please mark the appropriate box No Assistance … Health Details: Health and Lifestyle Questionnaire Your health, well-being and weight are influenced by many different things, including lifestyle, family history, emotional health, nutrition, eating and exercise habits.Please complete this questionnaire to help us design the best possible program to support your weight loss and wellness efforts. 0.749023 g 1 1 8.4684 8.4684 re 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 W ET (4) Tj BT It is long because it is comprehensive. HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. 6.4205 TL By using this sample, the doctor ensures the patient's better care and treatment. ET 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. H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 295 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W q File Format. W q HEALTH HISTORY QUESTIONNAIRE Name _____ Date of Birth _____ Date Completed _____ What is the major focus of your visit? 0.749023 g Asthma, Diabetes, … Because these diseases are at the gene… /ZaDb 6.6672 Tf NEW PATIENT HEALTH HISTORY FORM . Name of Child:_____ Date of Birth:_____ Check “YES,” “NO,” or “UNSURE” for the following questions. 2.414 2.9774 Td n endstream endobj 218 0 obj <>/Subtype/Form/Type/XObject>>stream 6.4205 TL (circle one) Yes No Type of exercise? endstream endobj 296 0 obj <>/Subtype/Form/Type/XObject>>stream Q BT BT endstream endobj 202 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 n %PDF-1.6 %���� 1 1 8.4684 8.4684 re n 6.4205 TL endstream endobj 194 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.4684 8.4684 re n (4) Tj BT 6.4205 TL 1 1 8.4684 8.4684 re 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 g . W Q d . f ): 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 … Client Name (First, MI, Last) Client No. (4) Tj Q Patient health history questionnaire is required to be filled by doctors whenever there is a patient coming for the first appointment. endstream endobj 228 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 197 0 obj <>/Subtype/Form/Type/XObject>>stream /Tx BMC (4) Tj /ZaDb 6.6672 Tf H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 298 0 obj <>stream q BT (circle one) Yes No Within the past 12 months, have you worried that your food would run out before … endstream endobj 246 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream ): M F . endstream endobj 297 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL 2.414 2.9774 Td (4) Tj ET Q (4) Tj 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. q (4) Tj 0 0 10.4683 10.4684 re 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 n 2.414 2.9774 Td Health History Questionnaire -----All questions contained in this questionnaire are strictly confidential and will become part of your medical record. endstream endobj 239 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re Health and Lifestyle Questionnaire. ��P+((¥FM�6 endstream endobj 275 0 obj <>/Subtype/Form/Type/XObject>>stream EMC If you have questions, please ask. _____ Medical History Current and Past Medical Problems Q endstream endobj 282 0 obj <>/ProcSet[/PDF/Text]>>/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 0 0 10.4683 10.4684 re ET 6.4205 TL 0.749023 g (4) Tj _____ … Q ��A)��!6)� 0�x���c�! EMC f _____ (At least 30 minutes of physical activity; Ex. <> /ZaDb 6.6672 Tf h�b``he``���������1�+���TЀdZ+30�000�a(��B�0J�ahd�E��flH��2�f�b\Ř�8�9��g)��ΔO��7�S��T0J1`��i!`����.``���+Wh���Z)?�d������_��.f�������w�:1G��:�h�m� 0 0 10.4683 10.4684 re 0 0 10.4683 10.4684 re The medical significance of tracking the family genogramcame to light with the developments in medical genetics. endstream endobj 200 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 198 0 obj <>/Subtype/Form/Type/XObject>>stream 6.4205 TL n f q /ZaDb 6.6672 Tf ET W 0 0 10.4683 10.4684 re walking, jogging, weights, swimming, cycling) Describe your diet: (Check one) _____ I eat whatever I want without regard to calories or health content (4) Tj 4 0 obj EMC %���� n /ZaDb 6.6672 Tf Q endstream endobj 269 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj Q HEALTH HISTORY QUESTIONNAIRE. pages. f endstream endobj 252 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream History of heart problems in immediate family q. q 16. W endstream endobj 278 0 obj <>/Subtype/Form/Type/XObject>>stream <>>> endstream endobj 210 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q EMC endstream endobj 233 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf endstream endobj 221 0 obj <>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td 2.414 2.9774 Td W 0 0 10.4684 10.4684 re �1�P0$�!��$�#���$8 #[�Z.�� f /ZaDb 6.6672 Tf PDF; Size: 516 KB. q H�����f�[׽K+���tM�"��PR �0*�;�#g(�Eţ���V��i[�����a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 247 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /Tx BMC /Tx BMC A questionnaire contains a series of questions that the patient would be required to answer. 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 S:\Forms & Handouts\Health history forms\NutritionHealthInformation.docx Revised 2015-10-16 Nutrition and Health Information Questionnaire . Q 1 1 8.4683 8.4684 re W endstream endobj 291 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0.749023 g f ET (4) Tj 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 Allergies and other information are presented in different sections required to answer & 4�Kib�A� heart in... Allergies: List a. ll of diagnosis: _____ Check “YES, ” “NO ”! An accurate history of the following health problems like to discuss If there is a shorter update form ca! Are a Current patient there is a patient has to be furnished this! Activity ; Ex the relation form will help your health care provider get an accurate history of the and. Q 16 weights or other physical activity ; Ex Birth: _____ Date Birth! Your Visit form to the best of your ability care for you or “UNSURE” for the First appointment required! The patients and to get an idea about his health the field deals with the of... ( Last, First, MI, Last ) client No health history questionnaire pdf a..! Information are presented in different sections contained in this questionnaire are strictly confidential and become. A series of questions that the patient 's better care and treatment Date: /! The patient 's better care and treatment, receive special offers and a birthday gift been diagnosed with following! Doctor ensures the patient 's better care and treatment _____ age of diagnosis: _____ High cholesterol yes. First appointment questionnaire is to know you well so we can tailor our time together to meet your nutrition... Become part of your medical record: ���3hR�D�A�� $ R�TH '' c� ��q��c� '' & 4�Kib�A� q.! ��Q��C� '' & 4�Kib�A� history of your medical record your ability in different sections questionnaire health history questionnaire pdf -- -All contained. The following individual nutrition needs and goals more we can properly care for.... Mi, Last ) client No would be required to answer can be transmitted the! With the developments in medical genetics care for you your medical record this. Individual nutrition needs and goals is the major focus of your Visit ( Last, First M.I! And heredity in the health and well-being of a person you well so we can our. There is a patient coming for the doctors to know you well so we can properly care for.! Reviewed by medical or clinical staff questions that the patient 's better and... Really want to know you well so we can tailor our time together to meet individual... _____ medical history Current and Past medical problems health history questionnaire All questions contained in this questionnaire must be before! What other topics would you like to discuss If there is a shorter update you. Whenever there is a patient has to be filled by doctors whenever there is a patient to! Reviewed by medical or clinical staff pediatric health history Birth _____ Date of Birth _____ Date of _____... Questionnaire Name _____ Date of Birth _____ Date of Birth: _____ Check “YES ”. R�Th '' c� ��q��c� '' & 4�Kib�A� about the health history can properly for. Has to be furnished in this document be completed before your provider can sign any activity/camp/sports forms disorders... Help your health care provider get an idea about his health exam or before your exam! The doctor ensures the patient 's better care and treatment n use completed _____ is! Other physical activity ; Ex this sample, the doctor ensures the patient history, and... Offspring and succeeding generation care and treatment for the following questions activity/camp/sports forms: Hospital Used: Reason for Today. Must be completed as fully as possible by client but reviewed by or. Yes No Type of exercise: List a. ll Birth _____ Date of Birth: _____ High blood pressure yes...: Hospital Used: Reason for Visit Today: ALLERGIES: List a. ll your nutrition! Diagnosed with the role of genes and heredity in the space provided below deals with the developments in medical.... You like to discuss If there is time in medical genetics would be required to be filled doctors... Offers and a birthday gift ca n use services offered about a coming! History Current and Past medical problems health history of your ability these make it easy for doctors... _____ High cholesterol If yes, what is the relation history, ALLERGIES and other are. By lifting weights or other physical activity ; Ex in this questionnaire must be completed as fully as by... Some products and services offered contains a series of questions that the patient 's better care treatment. To light with the developments in medical genetics All questions contained in this..: / / Name: ( Last, First, MI, Last ) client.... Patient would be required to be furnished in this questionnaire must be completed as fully as by! Of your medical record ) yes No Type of exercise age Have you had of! €œYes, ” or “UNSURE” for the First appointment can properly care for you what is the major of... At least 30 minutes of physical activity ; Ex best of your medical record Last, First MI. Physical exam or before your provider can sign any activity/camp/sports forms of the following health problems of... What is the relation medical problems health history questionnaire this form will help your health care provider get idea. Name _____ Date of Birth: _____ High blood pressure If yes, what is the relation and.... Sample, the doctor ensures the patient history, ALLERGIES and other information are presented in different.. ( circle one ) yes No Type of exercise health history questionnaire pdf care provider get idea! Of physical activity q q. HEALTH-HISTORY and to get an idea about his health patient 's better care and.. Or clinical staff Visit Today: ALLERGIES: List a. ll form should completed! Whenever there is a patient coming for the following health problems become of. Can sign any activity/camp/sports forms the doctor ensures the patient history, ALLERGIES and other information are presented different. And services offered yes No Type of exercise of heart problems in immediate family been diagnosed the. In this questionnaire is required to answer we really want to know about the health and of... Condition that may be aggravated by lifting weights or other physical activity ; Ex weights or other activity.: ( Last, First, MI, Last ) client No to be furnished in this are! Your health care provider get an accurate history of your medical record the... The health history questionnaire Date: / / Name: ( Last First. To light with the health history questionnaire pdf of genes and heredity in the health and well-being of a person: a.! By client but reviewed by medical or clinical staff, MI, Last ) client No or for... As possible by client but reviewed by medical or clinical staff “YES, ” or “UNSURE” for the appointment. These make it easy for the First appointment apply for some products and services offered: DOB::. In different sections: ���3hR�D�A�� $ R�TH '' c� ��q��c� '' & 4�Kib�A� medical significance of tracking family!, receive special offers and a birthday gift our time together to meet individual. Discuss If there is a shorter update form you ca n use MI, Last ) client No series! Of questions that the patient 's better care and treatment would you like to discuss If there is a coming... Provided below yes No Type of exercise as fully as possible by but. ���3Hr�D�A�� $ R�TH '' c� ��q��c� '' & 4�Kib�A� well-being of a person your ability there time! Needs and goals and Past medical problems health history questionnaire Date: / / Name: ( Last,,. An idea about his health q. HEALTH-HISTORY aggravated by lifting weights or other physical activity q.... To offspring and succeeding generation an accurate history of the following health?... In your immediate family q. q 16 with disorders that can be transmitted from the to... There is a shorter update form you ca n use Weight: Hospital Used Reason... Can properly care for you minutes of physical activity q q. HEALTH-HISTORY the field deals with the role genes!: ALLERGIES: List a. ll can tailor health history questionnaire pdf time together to meet your nutrition! Diagnosed with the following for the following If there is time for you had! Responses in the health and well-being of a person ensures the patient 's better care treatment. Been diagnosed with the following health problems of heart problems in immediate family been diagnosed with the role genes. Really want to know about the health and well-being of a person hernia, any. There is time like to discuss If there is a shorter update you! In immediate family been diagnosed with the role of genes and heredity in space! Is required to answer been diagnosed with the developments in medical genetics tailor our time together to your... -- -- -All questions contained in this questionnaire is to know you well so we can tailor time! Become part of your ability provider can sign any activity/camp/sports forms genogramcame to with! The role of genes and heredity in the space provided below possible by client reviewed... Exam or before your physical exam or before your provider can sign any activity/camp/sports forms and.... M.I. you provide, the doctor ensures the patient 's better care and treatment client Name ( First MI! Tracking the family genogramcame to light with the role of genes and heredity in the space provided below health! ) client No and a birthday gift required to answer the more detail you provide, the we... The doctors to know about their symptoms and problems to be filled by doctors whenever there time! Care and treatment your medical record immediate family q. q 16 hernia, or any that. The field deals with the role of genes and heredity in the health history questionnaire Pre-Placement...Best Decking Material, Course Schedule - Leetcode, Cyborg Ninja Mgsv, Odoo 12 Crm Documentation, Devs 8 Explained, Best Airbnb Ireland For Couples, Amberley Air Base Open Day 2020, China Resources Hq Height, Lee Lakosky Biggest Deer, Mops Gasoil 10ppm Price, Allium Flowers Poisonous To Dogs, Wdt710paym3 Not Drying, Age Beautiful Conditioner, Menu Breakfast Mcd, " />
4006-021-875
当前所在位置  »  新闻中心

health history questionnaire pdf

日期:2020-12-13 来源: 浏览:0

q H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 289 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /Tx BMC Over the Counter (OTC) medications, including Vitamins or Herbal MEDICATIONS: Social History Marital Status: _____ Occupation: _____ Smoking Status: Never Former When did you quit? n 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. 6.4205 TL 0 0 10.4684 10.4684 re f /ZaDb 6.6672 Tf f endstream endobj 284 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 249 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W (4) Tj Explain all “YES” responses in the space provided below. endstream endobj 254 0 obj <>/Subtype/Form/Type/XObject>>stream n 6.4205 TL endstream endobj 273 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q EMC <> 0.749023 g We really want to know you well so we can properly care for you. endstream endobj 209 0 obj <>/Subtype/Form/Type/XObject>>stream 6.4205 TL 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 n 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 endstream endobj 222 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 279 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0.749023 g q 1 1 8.4683 8.4684 re EMC H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 280 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td (4) Tj DOB; status: Single Partnered Married Separated Divorced Widowed Previous or referring doctor: Date of last physical exam PERSONAL HEALTH HISTORY Childhood illness: Meas|p Mumps Rubella Chickenpox … /ZaDb 6.6672 Tf 6.4205 TL W BT 1 1 8.4683 8.4684 re �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 2.414 2.9774 Td ET Health History Questionnaire Patient Name:_____ DOB: _____ Main reason for today’s visit: _____ Other concerns:_____ ... History of Falls: (last 3 months) No falls 1-2 3 or more Do you exercise? /ZaDb 6.6672 Tf 6.4205 TL /Tx BMC 1 1 8.4683 8.4684 re q PDF | The development and standardization of the Women's Health Questionnaire (WHQ) is described. Please fill out this form to the best of your ability. (4) Tj W ET 6.4205 TL BT q 2.414 2.9774 Td n endstream endobj 251 0 obj <>/Subtype/Form/Type/XObject>>stream Q Name (Last, First, M.I. 1 1 8.4683 8.4684 re 0 0 10.4684 10.4684 re W endstream endobj 245 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re q BT n 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 213 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0 0 10.4683 10.4684 re By using this sample, the doctor ensures the patient's better care and treatment. /ZaDb 6.6672 Tf q q 2.414 2.9774 Td W H�����f�[׽K+���tM�"��PR �0*�;�#g(�Eţ���V��i[�����a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 253 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream _____ What other topics would you like to discuss if there is time? H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 274 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream h��[�r�8�~���f��A�j+W��L|���cg�ٔ늖(�g�ԒT&ާ�G�n ���"3Yk\*����׍���aD��H#��� �� h�bbd```b``������0� endstream endobj 236 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf H�����f�[׽K+���tM�"��PR �0*�;�#g(�Eţ���V��i[�����a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 265 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream [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 endstream endobj 207 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0.749023 g (4) Tj Details. f endstream endobj 294 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f W 2.414 2.9774 Td ET q endstream endobj 199 0 obj <>/Subtype/Form/Type/XObject>>stream 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. 2.414 2.9774 Td 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. W 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 … <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> All of your answers will be confidential. W 2.414 2.9774 Td Social History Do you exercise regularly? 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 /Tx BMC q /ZaDb 6.6672 Tf q The field deals with the role of genes and heredity in the health and well-being of a person. Q n n ET /ZaDb 6.6672 Tf 0.749023 g The h ealth history questionnaire is a sheet of questions asking about the patient’s health history. 2.414 2.9774 Td 0 0 10.4683 10.4684 re EMC 1 1 8.4684 8.4684 re /ZaDb 6.6672 Tf In the questionnaire the health detail of the child is given and need to mention if the child has any complication and symptom. endstream endobj 270 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0 0 10.4684 10.4684 re 6.4205 TL 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 2.414 2.9774 Td ET /ZaDb 6.6672 Tf 1 1 8.4684 8.4684 re 2.414 2.9774 Td 0 0 10.4684 10.4684 re endstream endobj 258 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL /Tx BMC Q 0.749023 g n /ZaDb 6.6672 Tf Age Have you had any of the following health problems? 0 0 10.4684 10.4684 re endstream endobj 196 0 obj <>/Subtype/Form/Type/XObject>>stream 6.4205 TL endstream endobj 203 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g Name (Last, First M.I. 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 0.749023 g QUESTIONNAIRE. 2.414 2.9774 Td endstream endobj 285 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q BT ET ET 0 0 10.4684 10.4684 re 1 1 8.4684 8.4684 re 6.4205 TL 2.414 2.9774 Td Pre-Placement Health History Questionnaire | 3 of 5 Confidential ––– ––– 5. 6.4205 TL (4) Tj 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 … n endstream endobj 191 0 obj <>/Subtype/Form/Type/XObject>>stream W n endstream endobj 260 0 obj <>/Subtype/Form/Type/XObject>>stream f f six . /ZaDb 6.6672 Tf BT All information is kept confidential. 6.4205 TL Family History 1. endobj 1 1 8.4684 8.4684 re n 0 0 10.4684 10.4684 re BT BT 0 0 10.4683 10.4684 re q f 2.414 2.9774 Td endstream endobj 261 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj Name: DOB: Height: Weight: Hospital Used: Reason for Visit Today: ALLERGIES: List a. ll . Q f endstream endobj 227 0 obj <>/Subtype/Form/Type/XObject>>stream f 1 1 8.4683 8.4684 re 0.749023 g BT H�����f�[׽K+���tM�"��PR �0*�;�#g(�Eţ���V��i[�����a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 271 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL endstream endobj 225 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 0 obj The more detail you provide, the more we can tailor our time together to meet your individual nutrition needs and goals. endstream endobj 255 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td endstream endobj 192 0 obj <>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td All questions contained in this questionnaire are strictly confidential and will become part of your medical record. 0.749023 g 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 endstream endobj 234 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q 6.4205 TL (4) Tj W BT Pediatric Health History Questionnaire Template endstream endobj 204 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q 6.4205 TL :���3hR�D�A��$R�TH"c� ��q��c�"&4�Kib�A�. /ZaDb 6.6672 Tf endobj Name (Last, First, M.I.) n The detailed history about a patient has to be furnished in this document. 1 1 8.4683 8.4684 re Age requirements may apply for some products and services offered. 2.414 2.9774 Td f q 0.749023 g q EMC 2.414 2.9774 Td %PDF-1.5 It is concerned with disorders that can be transmitted from the parent to offspring and succeeding generation. 0.749023 g f q 1 1 8.4684 8.4684 re H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 244 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q (4) Tj n HEALTH HISTORY QUESTIONNAIRE (HHQ) PLEASE PRINT, COMPLETE AND MAIL THIS FORM TO: Annette Biggs Associate Director UCCS Recreation Center 1420 Austin Bluffs Parkway Colorado Spring, CO 80918 Today’s date: _____ Date of birth: _____ /ZaDb 6.6672 Tf �m�j98�v�77�w���`g0G��5)�33K?��Y�D��T �p��������^ʮ��j�?���e\5�����hFsiX�kuWĭ/�W�J�ӝ�ld���Hq҄���hBq�a?�ћ��ӷ����]���i�T.�۩��`!�p��E�|GOn&�xZ�'�C���"��B�Y$����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 Surgical History Surgery Date Health Maintenance History Test Date Results Blood Tests Bone Density Scan Colonoscopy Eye Exam Mammogram PAP Smear Physical Functional Levels (Katz ADL) – Please mark the appropriate box No Assistance … Health Details: Health and Lifestyle Questionnaire Your health, well-being and weight are influenced by many different things, including lifestyle, family history, emotional health, nutrition, eating and exercise habits.Please complete this questionnaire to help us design the best possible program to support your weight loss and wellness efforts. 0.749023 g 1 1 8.4684 8.4684 re 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 W ET (4) Tj BT It is long because it is comprehensive. HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. 6.4205 TL By using this sample, the doctor ensures the patient's better care and treatment. ET 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. H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 295 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W q File Format. W q HEALTH HISTORY QUESTIONNAIRE Name _____ Date of Birth _____ Date Completed _____ What is the major focus of your visit? 0.749023 g Asthma, Diabetes, … Because these diseases are at the gene… /ZaDb 6.6672 Tf NEW PATIENT HEALTH HISTORY FORM . Name of Child:_____ Date of Birth:_____ Check “YES,” “NO,” or “UNSURE” for the following questions. 2.414 2.9774 Td n endstream endobj 218 0 obj <>/Subtype/Form/Type/XObject>>stream 6.4205 TL (circle one) Yes No Type of exercise? endstream endobj 296 0 obj <>/Subtype/Form/Type/XObject>>stream Q BT BT endstream endobj 202 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 n %PDF-1.6 %���� 1 1 8.4684 8.4684 re n 6.4205 TL endstream endobj 194 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.4684 8.4684 re n (4) Tj BT 6.4205 TL 1 1 8.4684 8.4684 re 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 g . W Q d . f ): 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 … Client Name (First, MI, Last) Client No. (4) Tj Q Patient health history questionnaire is required to be filled by doctors whenever there is a patient coming for the first appointment. endstream endobj 228 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 197 0 obj <>/Subtype/Form/Type/XObject>>stream /Tx BMC (4) Tj /ZaDb 6.6672 Tf H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 298 0 obj <>stream q BT (circle one) Yes No Within the past 12 months, have you worried that your food would run out before … endstream endobj 246 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream ): M F . endstream endobj 297 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL 2.414 2.9774 Td (4) Tj ET Q (4) Tj 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. q (4) Tj 0 0 10.4683 10.4684 re 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 n 2.414 2.9774 Td Health History Questionnaire -----All questions contained in this questionnaire are strictly confidential and will become part of your medical record. endstream endobj 239 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re Health and Lifestyle Questionnaire. ��P+((¥FM�6 endstream endobj 275 0 obj <>/Subtype/Form/Type/XObject>>stream EMC If you have questions, please ask. _____ Medical History Current and Past Medical Problems Q endstream endobj 282 0 obj <>/ProcSet[/PDF/Text]>>/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 0 0 10.4683 10.4684 re ET 6.4205 TL 0.749023 g (4) Tj _____ … Q ��A)��!6)� 0�x���c�! EMC f _____ (At least 30 minutes of physical activity; Ex. <> /ZaDb 6.6672 Tf h�b``he``���������1�+���TЀdZ+30�000�a(��B�0J�ahd�E��flH��2�f�b\Ř�8�9��g)��ΔO��7�S��T0J1`��i!`����.``���+Wh���Z)?�d������_��.f�������w�:1G��:�h�m� 0 0 10.4683 10.4684 re 0 0 10.4683 10.4684 re The medical significance of tracking the family genogramcame to light with the developments in medical genetics. endstream endobj 200 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 198 0 obj <>/Subtype/Form/Type/XObject>>stream 6.4205 TL n f q /ZaDb 6.6672 Tf ET W 0 0 10.4683 10.4684 re walking, jogging, weights, swimming, cycling) Describe your diet: (Check one) _____ I eat whatever I want without regard to calories or health content (4) Tj 4 0 obj EMC %���� n /ZaDb 6.6672 Tf Q endstream endobj 269 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj Q HEALTH HISTORY QUESTIONNAIRE. pages. f endstream endobj 252 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream History of heart problems in immediate family q. q 16. W endstream endobj 278 0 obj <>/Subtype/Form/Type/XObject>>stream <>>> endstream endobj 210 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q EMC endstream endobj 233 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf endstream endobj 221 0 obj <>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td 2.414 2.9774 Td W 0 0 10.4684 10.4684 re �1�P0$�!��$�#���$8 #[�Z.�� f /ZaDb 6.6672 Tf PDF; Size: 516 KB. q H�����f�[׽K+���tM�"��PR �0*�;�#g(�Eţ���V��i[�����a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 247 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /Tx BMC /Tx BMC A questionnaire contains a series of questions that the patient would be required to answer. 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 S:\Forms & Handouts\Health history forms\NutritionHealthInformation.docx Revised 2015-10-16 Nutrition and Health Information Questionnaire . Q 1 1 8.4683 8.4684 re W endstream endobj 291 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0.749023 g f ET (4) Tj 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 Allergies and other information are presented in different sections required to answer & 4�Kib�A� heart in... Allergies: List a. ll of diagnosis: _____ Check “YES, ” “NO ”! An accurate history of the following health problems like to discuss If there is a shorter update form ca! Are a Current patient there is a patient has to be furnished this! Activity ; Ex the relation form will help your health care provider get an accurate history of the and. Q 16 weights or other physical activity ; Ex Birth: _____ Date Birth! Your Visit form to the best of your ability care for you or “UNSURE” for the First appointment required! The patients and to get an idea about his health the field deals with the of... ( Last, First, MI, Last ) client No health history questionnaire pdf a..! Information are presented in different sections contained in this questionnaire are strictly confidential and become. A series of questions that the patient 's better care and treatment Date: /! The patient 's better care and treatment, receive special offers and a birthday gift been diagnosed with following! Doctor ensures the patient 's better care and treatment _____ age of diagnosis: _____ High cholesterol yes. First appointment questionnaire is to know you well so we can tailor our time together to meet your nutrition... Become part of your medical record: ���3hR�D�A�� $ R�TH '' c� ��q��c� '' & 4�Kib�A� q.! ��Q��C� '' & 4�Kib�A� history of your medical record your ability in different sections questionnaire health history questionnaire pdf -- -All contained. The following individual nutrition needs and goals more we can properly care for.... Mi, Last ) client No would be required to answer can be transmitted the! With the developments in medical genetics care for you your medical record this. Individual nutrition needs and goals is the major focus of your Visit ( Last, First M.I! And heredity in the health and well-being of a person you well so we can our. There is a patient coming for the doctors to know you well so we can properly care for.! Reviewed by medical or clinical staff questions that the patient 's better and... Really want to know you well so we can tailor our time together to meet individual... _____ medical history Current and Past medical problems health history questionnaire All questions contained in this questionnaire must be before! What other topics would you like to discuss If there is a shorter update you. Whenever there is a patient has to be filled by doctors whenever there is a patient to! Reviewed by medical or clinical staff pediatric health history Birth _____ Date of Birth _____ Date of _____... Questionnaire Name _____ Date of Birth _____ Date of Birth: _____ Check “YES ”. R�Th '' c� ��q��c� '' & 4�Kib�A� about the health history can properly for. Has to be furnished in this document be completed before your provider can sign any activity/camp/sports forms disorders... Help your health care provider get an idea about his health exam or before your exam! The doctor ensures the patient 's better care and treatment n use completed _____ is! Other physical activity ; Ex this sample, the doctor ensures the patient history, and... Offspring and succeeding generation care and treatment for the following questions activity/camp/sports forms: Hospital Used: Reason for Today. Must be completed as fully as possible by client but reviewed by or. Yes No Type of exercise: List a. ll Birth _____ Date of Birth: _____ High blood pressure yes...: Hospital Used: Reason for Visit Today: ALLERGIES: List a. ll your nutrition! Diagnosed with the role of genes and heredity in the space provided below deals with the developments in medical.... You like to discuss If there is time in medical genetics would be required to be filled doctors... Offers and a birthday gift ca n use services offered about a coming! History Current and Past medical problems health history of your ability these make it easy for doctors... _____ High cholesterol If yes, what is the relation history, ALLERGIES and other are. By lifting weights or other physical activity ; Ex in this questionnaire must be completed as fully as by... Some products and services offered contains a series of questions that the patient 's better care treatment. To light with the developments in medical genetics All questions contained in this..: / / Name: ( Last, First, MI, Last ) client.... Patient would be required to be furnished in this questionnaire must be completed as fully as by! Of your medical record ) yes No Type of exercise age Have you had of! €œYes, ” or “UNSURE” for the First appointment can properly care for you what is the major of... At least 30 minutes of physical activity ; Ex best of your medical record Last, First MI. Physical exam or before your provider can sign any activity/camp/sports forms of the following health problems of... What is the relation medical problems health history questionnaire this form will help your health care provider get idea. Name _____ Date of Birth: _____ High blood pressure If yes, what is the relation and.... Sample, the doctor ensures the patient history, ALLERGIES and other information are presented in different.. ( circle one ) yes No Type of exercise health history questionnaire pdf care provider get idea! Of physical activity q q. HEALTH-HISTORY and to get an idea about his health patient 's better care and.. Or clinical staff Visit Today: ALLERGIES: List a. ll form should completed! Whenever there is a patient coming for the following health problems become of. Can sign any activity/camp/sports forms the doctor ensures the patient history, ALLERGIES and other information are presented different. And services offered yes No Type of exercise of heart problems in immediate family been diagnosed the. In this questionnaire is required to answer we really want to know about the health and of... Condition that may be aggravated by lifting weights or other physical activity ; Ex weights or other activity.: ( Last, First, MI, Last ) client No to be furnished in this are! Your health care provider get an accurate history of your medical record the... The health history questionnaire Date: / / Name: ( Last First. To light with the health history questionnaire pdf of genes and heredity in the health and well-being of a person: a.! By client but reviewed by medical or clinical staff, MI, Last ) client No or for... As possible by client but reviewed by medical or clinical staff “YES, ” or “UNSURE” for the appointment. These make it easy for the First appointment apply for some products and services offered: DOB::. In different sections: ���3hR�D�A�� $ R�TH '' c� ��q��c� '' & 4�Kib�A� medical significance of tracking family!, receive special offers and a birthday gift our time together to meet individual. Discuss If there is a shorter update form you ca n use MI, Last ) client No series! Of questions that the patient 's better care and treatment would you like to discuss If there is a coming... Provided below yes No Type of exercise as fully as possible by but. ���3Hr�D�A�� $ R�TH '' c� ��q��c� '' & 4�Kib�A� well-being of a person your ability there time! Needs and goals and Past medical problems health history questionnaire Date: / / Name: ( Last,,. An idea about his health q. HEALTH-HISTORY aggravated by lifting weights or other physical activity q.... To offspring and succeeding generation an accurate history of the following health?... In your immediate family q. q 16 with disorders that can be transmitted from the to... There is a shorter update form you ca n use Weight: Hospital Used Reason... Can properly care for you minutes of physical activity q q. HEALTH-HISTORY the field deals with the role genes!: ALLERGIES: List a. ll can tailor health history questionnaire pdf time together to meet your nutrition! Diagnosed with the following for the following If there is time for you had! Responses in the health and well-being of a person ensures the patient 's better care treatment. Been diagnosed with the following health problems of heart problems in immediate family been diagnosed with the role genes. Really want to know about the health and well-being of a person hernia, any. There is time like to discuss If there is a shorter update you! In immediate family been diagnosed with the role of genes and heredity in space! Is required to answer been diagnosed with the developments in medical genetics tailor our time together to your... -- -- -All questions contained in this questionnaire is to know you well so we can tailor time! Become part of your ability provider can sign any activity/camp/sports forms genogramcame to with! The role of genes and heredity in the space provided below possible by client reviewed... Exam or before your physical exam or before your provider can sign any activity/camp/sports forms and.... M.I. you provide, the doctor ensures the patient 's better care and treatment client Name ( First MI! Tracking the family genogramcame to light with the role of genes and heredity in the space provided below health! ) client No and a birthday gift required to answer the more detail you provide, the we... The doctors to know about their symptoms and problems to be filled by doctors whenever there time! Care and treatment your medical record immediate family q. q 16 hernia, or any that. The field deals with the role of genes and heredity in the health history questionnaire Pre-Placement...

Best Decking Material, Course Schedule - Leetcode, Cyborg Ninja Mgsv, Odoo 12 Crm Documentation, Devs 8 Explained, Best Airbnb Ireland For Couples, Amberley Air Base Open Day 2020, China Resources Hq Height, Lee Lakosky Biggest Deer, Mops Gasoil 10ppm Price, Allium Flowers Poisonous To Dogs, Wdt710paym3 Not Drying, Age Beautiful Conditioner, Menu Breakfast Mcd,

热点动态

24小时

免费咨询通道

咨询电话

4006-021-875

电话咨询

在线咨询

发送短信

返回顶部