health history questionnaire pdf

q ET 1 1 8.4683 8.4684 re BT ET 1 1 8.4683 8.4684 re ET 6.4205 TL EMC n endstream endobj 296 0 obj <>/Subtype/Form/Type/XObject>>stream n Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. 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ET /Tx BMC 0 0 10.4683 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 277 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 216 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f q Q f ): 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. (4) Tj EMC 6.4205 TL q Heart disease If yes, what is the relation? Over the Counter (OTC) medications, including Vitamins or Herbal MEDICATIONS: Social History Marital Status: _____ Occupation: _____ Smoking Status: Never Former When did you quit? 1 1 8.4683 8.4684 re n /ZaDb 6.6672 Tf endstream endobj 273 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re n 2.414 2.9774 Td n 2.414 2.9774 Td Plus, receive special offers and a birthday gift! Example of Patient Health History Questionnaire Form. 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 0.749023 g endstream endobj 219 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q 1 1 8.4684 8.4684 re q /ZaDb 6.6672 Tf 0 0 10.4683 10.4684 re The purpose of this questionnaire is to know about the health history of the patients and to get an idea about his health. Q /Tx BMC Q Q W 6.4205 TL 0 0 10.4683 10.4684 re %PDF-1.6 %�� (4) Tj /ZaDb 6.6672 Tf BT Explain all âYESâ responses in the space provided below. 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 FREE 10+ Sample Health Questionnaire Forms in PDF | MS Word A health questionnaire is usually used to record the medical history of a patient. 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 /ZaDb 6.6672 Tf 0 0 10.4684 10.4684 re 2.414 2.9774 Td 0 0 10.4684 10.4684 re 3 0 obj f 2.414 2.9774 Td endstream endobj 198 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf W 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¦ 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. 1 1 8.4683 8.4684 re %�� BT /ZaDb 6.6672 Tf 6.4205 TL q EMC q 1 1 8.4684 8.4684 re ET 6.4205 TL endstream endobj 297 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f q Q 1 1 8.4683 8.4684 re Q 1 1 8.4684 8.4684 re n endstream endobj 224 0 obj <>/Subtype/Form/Type/XObject>>stream Age Have you had any of the following health problems? 0.749023 g BT 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 (4) Tj 1 1 8.4684 8.4684 re ��$"F-��S��Tk"M� EMC H�E��}�+��N��M+��[�J�A��x��W�� o�U�.x-ό}��w�DTcN0��4ju�7�1O��1q�W� )�y endstream endobj 295 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential. f 0.749023 g 2.414 2.9774 Td 2.414 2.9774 Td 0.749023 g BT f ET endstream endobj 188 0 obj <>/Subtype/Form/Type/XObject>>stream n HEALTH HISTORY QUESTIONNAIRE This form should be completed as fully as possible by client but reviewed by medical or clinical staff. W 0.749023 g Asthma, Diabetes, â¦ 0.749023 g 0 0 10.4683 10.4684 re 0 0 10.4684 10.4684 re Download. W 0 0 10.4683 10.4684 re six . /Tx BMC q 1 1 8.4683 8.4684 re BT 0.749023 g /ZaDb 6.6672 Tf 1 1 8.4683 8.4684 re 6.4205 TL f /ZaDb 6.6672 Tf n ET /ZaDb 6.6672 Tf endstream endobj 209 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj 1 1 8.4683 8.4684 re HEALTH HISTORY QUESTIONNAIRE. (4) Tj endstream endobj 284 0 obj <>/Subtype/Form/Type/XObject>>stream W BT endstream endobj 202 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream BT 184 0 obj <> endobj 319 0 obj <>/Filter/FlateDecode/ID[<6B891314069B4CCCBD832608282591E1>]/Index[184 207]/Info 183 0 R/Length 188/Prev 101030/Root 185 0 R/Size 391/Type/XRef/W[1 3 1]>>stream (4) Tj 2.414 2.9774 Td 2.414 2.9774 Td EMC endstream endobj 267 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream EMC 6.4205 TL (4) Tj x��]]�ݶ�}W��}��ZQ��ʖmɑ��X�M��}��;i��/�r�> P�MU�a��}��w��7_|��P��ϟ|q�߇ꪶ��>ԇ��;L��_~w�y��̅��>PF�>�_��MU�^�5B|1~�h~v��?>|��ų��G��g_�<>j.��|��E_��:��O��??|�]Ӷ�^�s�8/_=��ώf��?�'�j�^s�k/��|q8,>r��yS�Um��vUW�^�ׇ��6M5n|��Tw��_�? 2.414 2.9774 Td ET W q ET endstream endobj 279 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f 1 1 8.4683 8.4684 re 1 1 8.4684 8.4684 re W /Tx BMC n endstream endobj 221 0 obj <>/Subtype/Form/Type/XObject>>stream 0 0 10.4684 10.4684 re Name (Last, First M.I. 2.414 2.9774 Td n W ET �1�P0$�!��$�#��$8 #[�Z.�� Name (Last, First, M.I.) H�E��}�+��N��M+��[�J�A��x��W�� o�U�.x-ό}��w�DTcN0��4ju�7�1O��1q�W� )�y endstream endobj 283 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q (4) Tj endstream endobj 251 0 obj <>/Subtype/Form/Type/XObject>>stream ET 1 1 8.4684 8.4684 re /ZaDb 6.6672 Tf 2.414 2.9774 Td The patient history, allergies and other information are presented in different sections. 0 0 10.4684 10.4684 re W ET 6.4205 TL Name (Last, First, M.I. 2.414 2.9774 Td ET All responses are confidential. W endstream endobj 230 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj known allergies No Known Dru. :��3hR�D�A��$R�TH"c� ��q��c�"&4�Kib�A�. _____ What other topics would you like to discuss if there is time? endstream endobj 285 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 0 obj 6.4205 TL 2.414 2.9774 Td 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. endstream endobj 272 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf endstream endobj 240 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re 0.749023 g /ZaDb 6.6672 Tf Name of Child:_____ Date of Birth:_____ Check âYES,â âNO,â or âUNSUREâ for the following questions. 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. endstream endobj 237 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream File Format. 2.414 2.9774 Td Q n Q NEW PATIENT HEALTH HISTORY FORM . /Tx BMC Q 0 0 10.4684 10.4684 re 6.4205 TL /ZaDb 6.6672 Tf endstream endobj 201 0 obj <>/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 BT /ZaDb 6.6672 Tf q 2 0 obj 0 0 10.4684 10.4684 re /ZaDb 6.6672 Tf endstream endobj 194 0 obj <>/Subtype/Form/Type/XObject>>stream 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 _____ What symptoms are you having? These make it easy for the doctors to know about their symptoms and problems. 0 0 10.4683 10.4684 re BT H��f�[׽K+��tM�"��PR �0*�;�#g(�Eţ��V��i[��a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 223 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL ET /ZaDb 6.6672 Tf Q (4) Tj 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 2.414 2.9774 Td 1 1 8.4683 8.4684 re 0 0 10.4683 10.4684 re 6.4205 TL /ZaDb 6.6672 Tf BT endstream endobj 249 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Yes No How many times per week? 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 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. (4) Tj f 1 1 8.4684 8.4684 re Medical History Record PDF template lets you collect the patient's data such as personal information, contact information in an emergency case, general medical history. All questions contained in this questionnaire are strictly confidential and will become part of your medical record. Health History Questionnaire Patient Name:_____ DOB: _____ Main reason for todayâs visit: _____ Other concerns:_____ ... History of Falls: (last 3 months) No falls 1-2 3 or more Do you exercise? 6.4205 TL 2.414 2.9774 Td f 0.749023 g The field deals with the role of genes and heredity in the health and well-being of a person. We really want to know you well so we can properly care for you. weightlosscenterar.com. If you have questions, please ask. ET 0.749023 g endobj 6.4205 TL 0 0 10.4683 10.4684 re HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. n h��[�r�8�~��f��A�j+W��L|��cg�ٔ늖(�g�ԒT&ާ�G�n ��"3Yk\*��׍��aD��H#�� (4) Tj endstream endobj 215 0 obj <>/Subtype/Form/Type/XObject>>stream W EMC n endstream endobj 195 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 231 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf A questionnaire contains a series of questions that the patient would be required to answer. endstream endobj 243 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj BT 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. q Pre-Placement Health History Questionnaire | 3 of 5 Confidential âââ âââ 5. 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 (4) Tj 1 1 8.4684 8.4684 re ET 6.4205 TL 6.4205 TL BT PDF; Size: 516 KB. ET [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 0 10.4684 10.4684 re H��f�[׽K+��tM�"��PR �0*�;�#g(�Eţ��V��i[��a/�DTcN0��4�ju�!nzbް�=�k⎯ *O{ endstream endobj 253 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W Q q BT f C3h0&�K(� ��Br�ڀZA?B (4) Tj (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. 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. q 6.4205 TL /ZaDb 6.6672 Tf f 6.4205 TL /Tx BMC The medical significance of tracking the family genogramcame to light with the developments in medical genetics. 2.414 2.9774 Td Q 6.4205 TL W W It is concerned with disorders that can be transmitted from the parent to offspring and succeeding generation. (4) Tj endstream endobj 275 0 obj <>/Subtype/Form/Type/XObject>>stream Patient health history questionnaire is required to be filled by doctors whenever there is a patient coming for the first appointment. W BT f (4) Tj f endstream endobj 263 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 236 0 obj <>/Subtype/Form/Type/XObject>>stream 0 0 10.4683 10.4684 re /ZaDb 6.6672 Tf 0.749023 g n endstream endobj 248 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 257 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 294 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 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 292 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream ET n endstream endobj 212 0 obj <>/Subtype/Form/Type/XObject>>stream W 1 1 8.4684 8.4684 re 1 1 8.4683 8.4684 re <>>> f endstream endobj 207 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 199 0 obj <>/Subtype/Form/Type/XObject>>stream <> 0.749023 g q All information is kept confidential. W /ZaDb 6.6672 Tf f /ZaDb 6.6672 Tf n endstream endobj 287 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g h�bbd```b``��0� 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 /ZaDb 6.6672 Tf /Tx BMC 2.414 2.9774 Td W n /ZaDb 6.6672 Tf View our privacy â¦ 0 0 10.4683 10.4684 re BT n 0.749023 g W The more detail you provide, the more we can tailor our time together to meet your individual nutrition needs and goals. EMC 0 0 10.4684 10.4684 re 2.414 2.9774 Td <> ET 2.414 2.9774 Td (4) Tj EMC endstream endobj 189 0 obj <>/Subtype/Form/Type/XObject>>stream f 0.749023 g Q 6.4205 TL ET Q q 0 0 10.4684 10.4684 re Health History Questionnaire - New Patient -Gastroenterology MRN: NAME: BIRTHDATE: CSN: FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART. Q W ��A)��!6)� 0�x��c�! 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