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BT BT 1 1 8.4684 8.4684 re (4) Tj /ZaDb 6.6672 Tf (4) Tj Because these diseases are at the gene⦠1 1 8.4683 8.4684 re f 0 0 10.4683 10.4684 re 6.4205 TL W endstream endobj 202 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream n (4) Tj Q endstream endobj 213 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj endstream endobj 216 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q f endstream endobj 243 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream walking, jogging, weights, swimming, cycling) Describe your diet: (Check one) _____ I eat whatever I want without regard to calories or health content 0.749023 g <> ��A)��!6)� 0�x���c�! f 0.749023 g _____ Age of diagnosis: _____ High cholesterol If yes, what is the relation? 0.749023 g %PDF-1.6 %���� HEALTH HISTORY QUESTIONNAIRE. The patient history, allergies and other information are presented in different sections. 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ET f 2.414 2.9774 Td 0 0 10.4684 10.4684 re ET 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 (4) Tj ET 2.414 2.9774 Td (4) Tj ET Over the Counter (OTC) medications, including Vitamins or Herbal MEDICATIONS: Social History Marital Status: _____ Occupation: _____ Smoking Status: Never Former When did you quit? 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 6.4205 TL By using this sample, the doctor ensures the patient's better care and treatment. W q ET HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential. endstream endobj 218 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 235 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q 2.414 2.9774 Td 0.749023 g n (4) Tj endstream endobj 272 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. /ZaDb 6.6672 Tf 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 W HEALTH HISTORY QUESTIONNAIRE This form should be completed as fully as possible by client but reviewed by medical or clinical staff. W Q 0.749023 g W /ZaDb 6.6672 Tf ET Age requirements may apply for some products and services offered. endstream endobj 263 0 obj <>/Subtype/Form/Type/XObject>>stream BT n /Tx BMC 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 BT /Tx BMC 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 _____ Medical History Current and Past Medical Problems 6.4205 TL (4) Tj /ZaDb 6.6672 Tf BT 2.414 2.9774 Td The field deals with the role of genes and heredity in the health and well-being of a person. endstream endobj 267 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re Q 0 0 10.4684 10.4684 re /ZaDb 6.6672 Tf f endstream endobj 248 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj 1 1 8.4684 8.4684 re W 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 232 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream n Yes No How many times per week? endstream endobj 191 0 obj <>/Subtype/Form/Type/XObject>>stream f f n /ZaDb 6.6672 Tf n W endstream endobj 273 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /Tx BMC endstream endobj 239 0 obj <>/Subtype/Form/Type/XObject>>stream 0 0 10.4684 10.4684 re Q 2.414 2.9774 Td EMC 0 0 10.4684 10.4684 re endstream endobj 219 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f /ZaDb 6.6672 Tf A person is more susceptible to diseases like diabetes, hypertension, heart problems, cancer, and mental disorders when his or her family is positive for these disorders. /ZaDb 6.6672 Tf (circle one) Yes No Type of exercise? n W endstream endobj 215 0 obj <>/Subtype/Form/Type/XObject>>stream BT 1 1 8.4684 8.4684 re BT endstream endobj 296 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g 6.4205 TL 2.414 2.9774 Td Q SAMPLE LIFESTYLE AND HEALTH-HISTORY QUESTIONNAIRE Continued on the next page. 6.4205 TL Q /ZaDb 6.6672 Tf /ZaDb 6.6672 Tf Pre-Placement Health History Questionnaire | 3 of 5 Confidential âââ âââ 5. All responses are confidential. 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EMC n 0 0 10.4684 10.4684 re BT Asthma, Diabetes, ⦠It is long because it is comprehensive. q endstream endobj 209 0 obj <>/Subtype/Form/Type/XObject>>stream BT f Q endstream endobj 294 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream EMC endstream endobj 249 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 203 0 obj <>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td 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 View our privacy ⦠6.4205 TL endstream endobj 252 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 279 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj _____ ⦠q 1 1 8.4683 8.4684 re ET 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 ⦠stream (4) Tj endstream endobj 246 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream _____ Do you feel safe at home? q ET HEALTH HISTORY QUESTIONNAIRE DATE: / / NAME:(Last, First, M.I.) 2.414 2.9774 Td Patient health history questionnaire is required to be filled by doctors whenever there is a patient coming for the first appointment. endstream endobj 284 0 obj <>/Subtype/Form/Type/XObject>>stream 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 Todayâs date: _____ Date of birth: _____ W _____ (At least 30 minutes of physical activity; Ex. 0 0 10.4683 10.4684 re HEALTH HISTORY QUESTIONNAIRE This questionnaire must be completed before your physical exam or before your provider can sign any activity/camp/sports forms. f 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 234 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q 2.414 2.9774 Td 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 f W 1 1 8.4684 8.4684 re W q 0.749023 g 2.414 2.9774 Td <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> endstream endobj 276 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream EMC (4) Tj W n BT All of your answers will be confidential. /Tx BMC endstream endobj 282 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f f 0.749023 g endstream endobj 204 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream BT q ET ET 0.749023 g 6.4205 TL q 0 0 10.4683 10.4684 re q f The medical significance of tracking the family genogramcame to light with the developments in medical genetics. (4) Tj endstream endobj 188 0 obj <>/Subtype/Form/Type/XObject>>stream BT 0.749023 g 1 1 8.4683 8.4684 re /ZaDb 6.6672 Tf endstream endobj 201 0 obj <>/Subtype/Form/Type/XObject>>stream q BT endstream endobj 269 0 obj <>/Subtype/Form/Type/XObject>>stream BT 1 1 8.4684 8.4684 re The detailed history about a patient has to be furnished in this document. f File Format. f 0 0 10.4683 10.4684 re endstream endobj 297 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream BT n q 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 0.749023 g W Name: DOB: Height: Weight: Hospital Used: Reason for Visit Today: ALLERGIES: List a. ll . h�bbd```b``������0� (4) Tj /ZaDb 6.6672 Tf 6.4205 TL n 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 f (4) Tj HEALTH HISTORY QUESTIONNAIRE Name _____ Date of Birth _____ Date Completed _____ What is the major focus of your visit? n q 1 1 8.4684 8.4684 re q 2.414 2.9774 Td Q endstream endobj 231 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f f Allergies List all Prescribe. 0 0 10.4683 10.4684 re 6.4205 TL Q Health History . endstream endobj 287 0 obj <>/Subtype/Form/Type/XObject>>stream BT 6.4205 TL /ZaDb 6.6672 Tf Q W 6.4205 TL W 1 1 8.4683 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 268 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 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) â Please mark the appropriate box No Assistance ⦠0 0 10.4683 10.4684 re endstream endobj 230 0 obj <>/Subtype/Form/Type/XObject>>stream 6.4205 TL 2.414 2.9774 Td Name (Last, First, M.I. /Tx BMC /ZaDb 6.6672 Tf (4) Tj 1 1 8.4683 8.4684 re ET Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. 2.414 2.9774 Td ET ): 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 ⦠6.4205 TL 1 1 8.4683 8.4684 re ET H�����f�[K+���tM�"��PR �0*�;�#g(�Eţ���V��i[�����a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 211 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td 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 NEW PATIENT HEALTH HISTORY FORM . /ZaDb 6.6672 Tf q 0.749023 g 1 1 8.4683 8.4684 re 1 1 8.4684 8.4684 re q endstream endobj 225 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf q ): M F DOB: Marital status: Single Partnered Married Separated Divorced Widowed Previous or referring doctor: Date of last physical exam: PERSONAL HEALTH HISTORY List any medical problems that other doctors have diagnosed (i.e. PDF | The development and standardization of the Women's Health Questionnaire (WHQ) is described. 6.4205 TL Heart disease If yes, what is the relation? 0.749023 g 1 1 8.4684 8.4684 re Please fill in all . 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 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 n n endstream endobj 233 0 obj <>/Subtype/Form/Type/XObject>>stream Name of Child:_____ Date of Birth:_____ Check âYES,â âNO,â or âUNSUREâ for the following questions. 6.4205 TL BT The purpose of this questionnaire is to know about the health history of the patients and to get an idea about his health. 0 0 10.4684 10.4684 re ET endstream endobj 254 0 obj <>/Subtype/Form/Type/XObject>>stream W f W Pediatric Health History Questionnaire Template 0.749023 g EMC 0 0 10.4683 10.4684 re endobj q <> ET W (4) Tj f ): M F . 0 0 10.4684 10.4684 re 1 1 8.4683 8.4684 re EMC endstream endobj 240 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f ET C3h0&�K(� ��Br�ڀZA?B BT 2 0 obj �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��. 2.414 2.9774 Td DO NOT SEND TO HIM. /ZaDb 6.6672 Tf /Tx BMC n Please fill out this form to the best of your ability. (4) Tj W h��[�r�8�~���f��A�j+W��L|���cg�ٔ늖(�g�ԒT&ާ�G�n ���"3Yk\*�������aD��H#��� �� 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. f 2.414 2.9774 Td (4) Tj endstream endobj 260 0 obj <>/Subtype/Form/Type/XObject>>stream Q 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 292 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream g . Download. 1 1 8.4683 8.4684 re /ZaDb 6.6672 Tf 2.414 2.9774 Td Family History 1. The more detail you provide, the more we can tailor our time together to meet your individual nutrition needs and goals. six . ET 1 1 8.4683 8.4684 re ET 0.749023 g 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 EMC q 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 6.4205 TL 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 210 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf endstream endobj 236 0 obj <>/Subtype/Form/Type/XObject>>stream All information is kept confidential. 1 1 8.4684 8.4684 re x��]]�ݶ�}W���}��ZQ���ʖmɑ���X�M��}����;i����/�r�> P�MU�a��}������w�����7_|��P���ϟ|q�߇ꪶ���>ԇ��;L������_~w�y���̅��>PF�>�_�����MU�^�5B|1~�h~v����?>|��ų��G��g_�<>j.����|�����E_��:����O��??|�]Ӷ�^�s�8/_=���ώf��?�'�j�^s�k/���|q8,>r��yS�Um��vUW�^�ׇ��������6M5n|��Tw���_�? 2.414 2.9774 Td 0 0 10.4683 10.4684 re Do you experience any chronic pain or musculoskeletal problems that limit your ability to perform the essential functions of the job for which you are being considered? 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Health History Questionnaire - New Patient -Gastroenterology MRN: NAME: BIRTHDATE: CSN: FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART. 6.4205 TL W q 0 0 10.4684 10.4684 re (4) Tj �1�P0$�!��$�#���$8 #[�Z.�� 6.4205 TL 2.414 2.9774 Td Q q endstream endobj 193 0 obj <>/Subtype/Form/Type/XObject>>stream q 2.414 2.9774 Td endstream endobj 281 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g endstream endobj 291 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream n 2.414 2.9774 Td ( ) M ( ) F DOB: _ / _ / PRESENT PULMONARY HEALTH CONCERN(S) Please describe your current pulmonary problem(s) and why you are seeking consultation. 0 0 10.4683 10.4684 re endstream endobj 242 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 212 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g endobj EMC known allergies No Known Dru. n f Questionnaire . 0.749023 g ET n Q Q BT n 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 277 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 1 8.4684 8.4684 re W 0 0 10.4684 10.4684 re Name (Last, First M.I. _____ Age of diagnosis: _____ High blood pressure If yes, what is the relation? endstream endobj 237 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream If you are a current patient there is a shorter update form you ca n use. PDF; Size: 516 KB. 6.4205 TL DISCARD FORM AFTER ENTRY, USING CONFIDENTIAL RECYCLE. H�����f�[K+���tM�"��PR �0*�;�#g(�Eţ���V��i[�����a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 259 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 207 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 275 0 obj <>/Subtype/Form/Type/XObject>>stream n Example of Patient Health History Questionnaire Form. 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. 0.749023 g endstream endobj 224 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 266 0 obj <>/Subtype/Form/Type/XObject>>stream q ET /ZaDb 6.6672 Tf W /Tx BMC f Explain all âYESâ responses in the space provided below. BT endstream endobj 255 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 228 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f endstream endobj 221 0 obj <>/Subtype/Form/Type/XObject>>stream 6.4205 TL 2.414 2.9774 Td q /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 n 2.414 2.9774 Td (4) Tj 2.414 2.9774 Td 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 (4) Tj 0 0 10.4684 10.4684 re 2.414 2.9774 Td 1 0 obj (4) Tj f f 1 1 8.4684 8.4684 re 0.749023 g (4) Tj Q 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 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 BT q /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 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 6.4205 TL Age Have you had any of the following health problems? Health Questionnaire - Nutrition Assessment - Page 2 Client Insurance Form We are in-network providers of Blue Cross Blue Shield of Minnesota. 1 1 8.4684 8.4684 re 6.4205 TL Details. If you have questions, please ask. ET Hernia, or any condition that may be aggravated by lifting weights or other physical activity q q. HEALTH-HISTORY . Social History Do you exercise regularly? 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 BT endstream endobj 290 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf 2.414 2.9774 Td 3 0 obj 0.749023 g HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. 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 W Q n endstream endobj 264 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj 1 1 8.4684 8.4684 re Has anyone in your immediate family been diagnosed with the following? W n The h ealth history questionnaire is a sheet of questions asking about the patientâs health history. endstream endobj 197 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g ET 0 0 10.4684 10.4684 re A questionnaire contains a series of questions that the patient would be required to answer. q W FREE 10+ Sample Health Questionnaire Forms in PDF | MS Word A health questionnaire is usually used to record the medical history of a patient. 0.749023 g EMC /Tx BMC W History of heart problems in immediate family q. q 16. (4) Tj In the questionnaire the health detail of the child is given and need to mention if the child has any complication and symptom. /Tx BMC Q BT /Tx BMC ET /ZaDb 6.6672 Tf EMC f We really want to know you well so we can properly care for you. Q /ZaDb 6.6672 Tf 0.749023 g 6.4205 TL n (4) Tj Q BT EMC n endstream endobj 293 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf BT 0.749023 g _____ What other topics would you like to discuss if there is time? 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BT Q 6.4205 TL BT Q /Tx BMC W ET Q Health History Questionnaire -----All questions contained in this questionnaire are strictly confidential and will become part of your medical record. 2.414 2.9774 Td (4) Tj endstream endobj 198 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 190 0 obj <>/Subtype/Form/Type/XObject>>stream ET 0 0 10.4683 10.4684 re endstream endobj 206 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj 6.4205 TL endstream endobj 270 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream n 1 1 8.4684 8.4684 re 1 1 8.4683 8.4684 re 0.749023 g ET endstream endobj 257 0 obj <>/Subtype/Form/Type/XObject>>stream Q 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. 1 1 8.4684 8.4684 re ��P+((¥FM�6 /Tx BMC endstream endobj 189 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf %���� 2.414 2.9774 Td Client Name (First, MI, Last) Client No. 0.749023 g 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 ⦠W EMC n endstream endobj 199 0 obj <>/Subtype/Form/Type/XObject>>stream q (circle one) Yes No Within the past 12 months, have you worried that your food would run out before ⦠4 0 obj Q endstream endobj 285 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re 1 1 8.4683 8.4684 re /ZaDb 6.6672 Tf 0 0 10.4683 10.4684 re BT /Tx BMC Q 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 ⦠6.4205 TL 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 By using this sample, the doctor ensures the patient's better care and treatment. /ZaDb 6.6672 Tf _____ What symptoms are you having? 0.749023 g EMC 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 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. d . 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