health history questionnaire pdf

health history questionnaire pdf

0.749023 g 0.749023 g W W f q n 2.414 2.9774 Td (4) Tj q 0.749023 g 2.414 2.9774 Td _____ Medical History Current and Past Medical Problems n (4) Tj (4) Tj _____ How often? W stream 1 1 8.4683 8.4684 re W The detailed history about a patient has to be furnished in this document. Q 0.749023 g 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 Example of Patient Health History Questionnaire Form. endstream endobj 273 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (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 250 0 obj <>/ProcSet[/PDF/Text]>>/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 (4) Tj ET f 0 0 10.4683 10.4684 re 2.414 2.9774 Td Q ET 2 0 obj 1 1 8.4684 8.4684 re f 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. Details. q 0 0 10.4683 10.4684 re ��$"F-���S��Tk"M� q ��P+((¥FM�6 n endstream endobj 203 0 obj <>/Subtype/Form/Type/XObject>>stream Name (Last, First, M.I. known allergies No Known Dru. n W SAMPLE LIFESTYLE AND HEALTH-HISTORY QUESTIONNAIRE Continued on the next page. Please fill in all . 6.4205 TL f f f /ZaDb 6.6672 Tf /Tx BMC endstream endobj 251 0 obj <>/Subtype/Form/Type/XObject>>stream EMC <> ET ET 1 1 8.4684 8.4684 re 0.749023 g Download. q _____ Age of diagnosis: _____ High blood pressure If yes, what is the relation? BT n ET 1 1 8.4683 8.4684 re n endstream endobj 266 0 obj <>/Subtype/Form/Type/XObject>>stream ET 0 0 10.4684 10.4684 re 0 0 10.4683 10.4684 re Name of Child:_____ Date of Birth:_____ Check “YES,” “NO,” or “UNSURE” for the following questions. 0.749023 g 6.4205 TL Q f 6.4205 TL (4) Tj 0 0 10.4683 10.4684 re 0 0 10.4683 10.4684 re (circle one) Yes No Type of exercise? f 0.749023 g Q S:\Forms & Handouts\Health history forms\NutritionHealthInformation.docx Revised 2015-10-16 Nutrition and Health Information Questionnaire . BT W 0 0 10.4683 10.4684 re /ZaDb 6.6672 Tf 0 0 10.4683 10.4684 re ET 0.749023 g _____ What symptoms are you having? 0.749023 g History of heart problems in immediate family q. q 16. 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 191 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g 0 0 10.4684 10.4684 re 6.4205 TL f 0.749023 g f q W PDF; Size: 516 KB. 0.749023 g Yes No How many times per week? 6.4205 TL 0 0 10.4684 10.4684 re (4) Tj endstream endobj 192 0 obj <>/Subtype/Form/Type/XObject>>stream Name: DOB: Height: Weight: Hospital Used: Reason for Visit Today: ALLERGIES: List a. ll . endstream endobj 243 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 252 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Explain all “YES” responses in the space provided below. W 0 0 10.4684 10.4684 re 0 0 10.4684 10.4684 re 0.749023 g File Format. BT 1 1 8.4683 8.4684 re Social History Do you exercise regularly? 6.4205 TL 0 0 10.4684 10.4684 re /ZaDb 6.6672 Tf Page 4of 50-10079 VER: A/12 HIM: 08/12 Do Not File Health History Questionnaire - New Patient - Gastroenterology Review … All responses are confidential. 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BT endstream endobj 225 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 286 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) – Please mark the appropriate box No Assistance … 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 238 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj endstream endobj 210 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 q EMC endstream endobj 190 0 obj <>/Subtype/Form/Type/XObject>>stream f /Tx BMC f q (4) Tj q BT endstream endobj 234 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream BT 2.414 2.9774 Td EMC endstream endobj 193 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 196 0 obj <>/Subtype/Form/Type/XObject>>stream BT /ZaDb 6.6672 Tf /ZaDb 6.6672 Tf endstream endobj 219 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream n 0 0 10.4683 10.4684 re 0 0 10.4683 10.4684 re ET endstream endobj 212 0 obj <>/Subtype/Form/Type/XObject>>stream The medical significance of tracking the family genogramcame to light with the developments in medical genetics. /ZaDb 6.6672 Tf q Asthma, Diabetes, … (4) Tj (4) Tj 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� endstream endobj 293 0 obj <>/Subtype/Form/Type/XObject>>stream HEALTH HISTORY QUESTIONNAIRE Name _____ Date of Birth _____ Date Completed _____ What is the major focus of your visit? We really want to know you well so we can properly care for you. 1 1 8.4683 8.4684 re �m�j98�v�77�w���`g0G��5)�33K?��Y�D��T �p��������^ʮ��j�?���e\5�����hFsiX�kuWĭ/�W�J�ӝ�ld���Hq҄���hBq�a?�ћ��ӷ����]���i�T.�۩��`!�p��E�|GOn&�xZ�'�C���"��B�Y$����u;u쇱R�=�lov�8���Ҳݯ1��m�=o.�^.-M��6�e��k�u�0����Z�lN���$�g+��ޜ���[�KJ�{��� �������t}r �ۣ�]��o���vb�����`n������6����fJ�7��g���p#��j�*��MgoE�V-J�Uvb��T�D��ߘ�o������S����n!m:�G��.��Eٛ�ʣU�M��~��P��&��I�S�옦vX�l۪k[8O��. n 6.4205 TL 1 1 8.4684 8.4684 re 2.414 2.9774 Td n endstream endobj 264 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W /ZaDb 6.6672 Tf ): M F . f endstream endobj 296 0 obj <>/Subtype/Form/Type/XObject>>stream 0 0 10.4684 10.4684 re The more detail you provide, the more we can tailor our time together to meet your individual nutrition needs and goals. Has anyone in your immediate family been diagnosed with the following? f q 2.414 2.9774 Td endstream endobj 281 0 obj <>/Subtype/Form/Type/XObject>>stream Q endstream endobj 287 0 obj <>/Subtype/Form/Type/XObject>>stream Q �4dG6cq+�^�~ fb`��\�@����������c�9T�'� ,�� endstream endobj 185 0 obj <>/Metadata 5 0 R/PageLabels 180 0 R/Pages 182 0 R/StructTreeRoot 11 0 R/Type/Catalog/ViewerPreferences<>>> endobj 186 0 obj <>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 2/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 187 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 188 0 obj <>/Subtype/Form/Type/XObject>>stream The h ealth history questionnaire is a sheet of questions asking about the patient’s health history. BT 2.414 2.9774 Td BT /Tx BMC q 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: _____ (4) Tj 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 (4) Tj 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 213 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. q (4) Tj BT endstream endobj 221 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf f f W 6.4205 TL f 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���_�? /Tx BMC endstream endobj 194 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential. endstream endobj 290 0 obj <>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td Health History Questionnaire - New Patient -Gastroenterology MRN: NAME: BIRTHDATE: CSN: FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART. 0.749023 g endstream endobj 275 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. 1 1 8.4684 8.4684 re %PDF-1.5 1 1 8.4684 8.4684 re endstream endobj 282 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 2.414 2.9774 Td 1 1 8.4684 8.4684 re 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 q A questionnaire contains a series of questions that the patient would be required to answer. 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 f 6.4205 TL :���3hR�D�A��$R�TH"c� ��q��c�"&4�Kib�A�. 0.749023 g Age requirements may apply for some products and services offered. Name (Last, First, M.I. All of your answers will be confidential. Q 1 0 obj endstream endobj 215 0 obj <>/Subtype/Form/Type/XObject>>stream BT Q HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. 6.4205 TL 1 1 8.4683 8.4684 re The field deals with the role of genes and heredity in the health and well-being of a person. endstream endobj 206 0 obj <>/Subtype/Form/Type/XObject>>stream Q endstream endobj 216 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Q endstream endobj 201 0 obj <>/Subtype/Form/Type/XObject>>stream ET q 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 q 0 0 10.4684 10.4684 re endstream endobj 237 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream n Q /ZaDb 6.6672 Tf ET W Q endobj 6.4205 TL ET 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 Because these diseases are at the gene… 0.749023 g f 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. (4) Tj 6.4205 TL ET EMC endstream endobj 284 0 obj <>/Subtype/Form/Type/XObject>>stream 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? HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. BT BT BT q q W /Tx BMC q Q endstream endobj 207 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream d . 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. 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 0 0 10.4683 10.4684 re endstream endobj 222 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream EMC These make it easy for the doctors to know about their symptoms and problems. HEALTH HISTORY QUESTIONNAIRE This questionnaire must be completed before your physical exam or before your provider can sign any activity/camp/sports forms. 6.4205 TL ET W If you have questions, please ask. EMC /Tx BMC endstream endobj 272 0 obj <>/Subtype/Form/Type/XObject>>stream Health Questionnaire - Nutrition Assessment - Page 2 Client Insurance Form We are in-network providers of Blue Cross Blue Shield of Minnesota. 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