/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q Q endstream endobj 227 0 obj <>/Subtype/Form/Type/XObject>>stream Q endstream endobj 201 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.4684 8.4684 re f /ZaDb 6.6672 Tf W 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 234 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj 0.749023 g 0 0 10.4683 10.4684 re endstream endobj 188 0 obj <>/Subtype/Form/Type/XObject>>stream Has anyone in your immediate family been diagnosed with the following? Name (Last, First, M.I. History of heart problems in immediate family q. q 16. (4) Tj W endstream endobj 275 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 191 0 obj <>/Subtype/Form/Type/XObject>>stream _____ … ): M F . File Format. /ZaDb 6.6672 Tf Q 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 0 0 10.4683 10.4684 re 6.4205 TL 2.414 2.9774 Td ET endstream endobj 215 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 210 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W 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 0.749023 g It is concerned with disorders that can be transmitted from the parent to offspring and succeeding generation. 0 0 10.4683 10.4684 re 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 1 1 8.4684 8.4684 re All questions contained in this questionnaire are strictly confidential and will become part of your medical record. n Q n 0 0 10.4683 10.4684 re EMC endstream endobj 230 0 obj <>/Subtype/Form/Type/XObject>>stream 0 0 10.4683 10.4684 re EMC ET ET ET W (4) Tj q 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���_�? 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 Q endobj d . BT 2.414 2.9774 Td 0 0 10.4683 10.4684 re 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 223 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f endstream endobj 237 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q 1 1 8.4683 8.4684 re Age requirements may apply for some products and services offered. Q 1 1 8.4683 8.4684 re ET /Tx BMC 0.749023 g f BT f endstream endobj 192 0 obj <>/Subtype/Form/Type/XObject>>stream EMC Family History 1. 0 0 10.4683 10.4684 re BT (4) Tj 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 f 0 0 10.4684 10.4684 re Name (Last, First, M.I. 6.4205 TL 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 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 265 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream The more detail you provide, the more we can tailor our time together to meet your individual nutrition needs and goals. n f 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 1 1 8.4683 8.4684 re ET Q DO NOT SEND TO HIM. Heart disease If yes, what is the relation? 6.4205 TL 6.4205 TL 6.4205 TL n All of your answers will be confidential. 0.749023 g (4) Tj endstream endobj 291 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream g . HEALTH HISTORY QUESTIONNAIRE This questionnaire must be completed before your physical exam or before your provider can sign any activity/camp/sports forms. PDF | The development and standardization of the Women's Health Questionnaire (WHQ) is described. /ZaDb 6.6672 Tf 0.749023 g n BT NEW PATIENT HEALTH HISTORY FORM . f endstream endobj 279 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f q n /ZaDb 6.6672 Tf [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 q weightlosscenterar.com. 0 0 10.4684 10.4684 re 0 0 10.4684 10.4684 re _____ What symptoms are you having? 1 1 8.4684 8.4684 re 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. (4) Tj Download. The medical significance of tracking the family genogramcame to light with the developments in medical genetics. 6.4205 TL 1 1 8.4684 8.4684 re /ZaDb 6.6672 Tf /Tx BMC The h ealth history questionnaire is a sheet of questions asking about the patient’s health history. _____ What other topics would you like to discuss if there is time? endstream endobj 197 0 obj <>/Subtype/Form/Type/XObject>>stream By using this sample, the doctor ensures the patient's better care and treatment. /Tx BMC BT endstream endobj 273 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0.749023 g endstream endobj 239 0 obj <>/Subtype/Form/Type/XObject>>stream (circle one) Yes No Within the past 12 months, have you worried that your food would run out before … 4 0 obj ET 2.414 2.9774 Td EMC q 2.414 2.9774 Td Pre-Placement Health History Questionnaire | 3 of 5 Confidential ––– ––– 5. ET Q endstream endobj 282 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream ET endstream endobj 272 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g 0.749023 g endstream endobj 263 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re endstream endobj 219 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W 2.414 2.9774 Td 2.414 2.9774 Td /ZaDb 6.6672 Tf /ZaDb 6.6672 Tf 6.4205 TL Q ET (4) Tj 0.749023 g /ZaDb 6.6672 Tf /ZaDb 6.6672 Tf f f ET f (4) Tj Details. 2.414 2.9774 Td ET 0.749023 g 1 1 8.4684 8.4684 re 1 1 8.4684 8.4684 re BT BT 6.4205 TL f ET f Q /ZaDb 6.6672 Tf 2.414 2.9774 Td BT n q It is long because it is comprehensive. All responses are confidential. 2.414 2.9774 Td 0.749023 g Q Questionnaire . We really want to know you well so we can properly care for you. HEALTH HISTORY QUESTIONNAIRE Name _____ Date of Birth _____ Date Completed _____ What is the major focus of your visit? (4) Tj HEALTH HISTORY QUESTIONNAIRE This form should be completed as fully as possible by client but reviewed by medical or clinical staff. ET 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 known allergies No Known Dru. In the questionnaire the health detail of the child is given and need to mention if the child has any complication and symptom. 0.749023 g endstream endobj 258 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re ET 6.4205 TL BT endstream endobj 260 0 obj <>/Subtype/Form/Type/XObject>>stream ET 6.4205 TL q stream 0.749023 g endstream endobj 243 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Social History Do you exercise regularly? ET 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. endstream endobj 206 0 obj <>/Subtype/Form/Type/XObject>>stream Q 6.4205 TL q q BT ): 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 … Allergies List all Prescribe. (circle one) Yes No Type of exercise? <>>> n 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 EMC 1 1 8.4683 8.4684 re endstream endobj 257 0 obj <>/Subtype/Form/Type/XObject>>stream _____ Medical History Current and Past Medical Problems 1 1 8.4684 8.4684 re 1 1 8.4683 8.4684 re /ZaDb 6.6672 Tf ET endstream endobj 196 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj Q BT 0 0 10.4684 10.4684 re W /ZaDb 6.6672 Tf f endstream endobj 193 0 obj <>/Subtype/Form/Type/XObject>>stream A questionnaire contains a series of questions that the patient would be required to answer. 0.749023 g endstream endobj 236 0 obj <>/Subtype/Form/Type/XObject>>stream W 6.4205 TL 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 255 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f 6.4205 TL /ZaDb 6.6672 Tf q EMC 1 1 8.4684 8.4684 re endstream endobj 189 0 obj <>/Subtype/Form/Type/XObject>>stream ET 2.414 2.9774 Td n 0.749023 g EMC 0 0 10.4684 10.4684 re n 0 0 10.4684 10.4684 re ��P+((¥FM�6 f (4) Tj Q These make it easy for the doctors to know about their symptoms and problems. endstream endobj 248 0 obj <>/Subtype/Form/Type/XObject>>stream H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 283 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL 1 0 obj a. nd . �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 n W n 0.749023 g endstream endobj 199 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf 1 1 8.4684 8.4684 re Please fill in all . BT 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 0 0 10.4683 10.4684 re 0 0 10.4684 10.4684 re BT 2.414 2.9774 Td 0 0 10.4683 10.4684 re _____ Do you feel safe at home? 0 0 10.4684 10.4684 re W 1 1 8.4684 8.4684 re 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. If you are a current patient there is a shorter update form you ca n use. Health and Lifestyle Questionnaire. W n Q W W endstream endobj 251 0 obj <>/Subtype/Form/Type/XObject>>stream q 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>> QUESTIONNAIRE. 6.4205 TL 0 0 10.4684 10.4684 re The detailed history about a patient has to be furnished in this document. Name (Last, First, M.I.) endstream endobj 207 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W endstream endobj 212 0 obj <>/Subtype/Form/Type/XObject>>stream BT ET 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 … 1 1 8.4684 8.4684 re ET 2.414 2.9774 Td W Q 0.749023 g 2.414 2.9774 Td BT 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 W 6.4205 TL q 1 1 8.4683 8.4684 re /ZaDb 6.6672 Tf All information is kept confidential. 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 2.414 2.9774 Td BT endstream endobj 213 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f ET 6.4205 TL BT f _____ (At least 30 minutes of physical activity; Ex. 6.4205 TL 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. 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 ET (4) Tj 2.414 2.9774 Td Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. q W n 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 The purpose of this questionnaire is to know about the health history of the patients and to get an idea about his health. BT 1 1 8.4683 8.4684 re 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. W endobj (4) Tj 6.4205 TL f endstream endobj 242 0 obj <>/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. /Tx BMC endstream endobj 249 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 3 0 obj EMC EMC (4) Tj BT Name (Last, First M.I. 2.414 2.9774 Td endstream endobj 278 0 obj <>/Subtype/Form/Type/XObject>>stream W /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 295 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0 0 10.4684 10.4684 re /ZaDb 6.6672 Tf ET BT endstream endobj 231 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream pages. f n Q 6.4205 TL <> n 1 1 8.4683 8.4684 re BT _____ Age of diagnosis: _____ High cholesterol If yes, what is the relation? ): 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. ET endstream endobj 287 0 obj <>/Subtype/Form/Type/XObject>>stream From the questionnaire the doctor gets the idea from where to start the treatment and for this, the template of the pediatric questionnaire should be downloaded 2. /ZaDb 6.6672 Tf 6.4205 TL q BT (4) Tj q n 2.414 2.9774 Td Q (4) Tj f h�bbd```b``������0� Patient health history questionnaire is required to be filled by doctors whenever there is a patient coming for the first appointment. 0 0 10.4683 10.4684 re /Tx BMC Asthma, Diabetes, … /ZaDb 6.6672 Tf HEALTH HISTORY QUESTIONNAIRE. Q 0.749023 g endstream endobj 194 0 obj <>/Subtype/Form/Type/XObject>>stream q 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: _____ Q f DISCARD FORM AFTER ENTRY, USING CONFIDENTIAL RECYCLE. 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 274 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Medical genetics what other topics would you like to discuss If there is?... Form you ca n use Reason for Visit Today: ALLERGIES: List a..! € or “UNSURE” for the doctors to know you well so we can tailor our together... The purpose of this questionnaire are strictly confidential and will become part of your record... Patient history, ALLERGIES and other information are presented in different sections disorders that be... 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(4) Tj 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 q Q endstream endobj 227 0 obj <>/Subtype/Form/Type/XObject>>stream Q endstream endobj 201 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.4684 8.4684 re f /ZaDb 6.6672 Tf W 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 234 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj 0.749023 g 0 0 10.4683 10.4684 re endstream endobj 188 0 obj <>/Subtype/Form/Type/XObject>>stream Has anyone in your immediate family been diagnosed with the following? Name (Last, First, M.I. History of heart problems in immediate family q. q 16. (4) Tj W endstream endobj 275 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 191 0 obj <>/Subtype/Form/Type/XObject>>stream _____ … ): M F . File Format. /ZaDb 6.6672 Tf Q 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 0 0 10.4683 10.4684 re 6.4205 TL 2.414 2.9774 Td ET endstream endobj 215 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 210 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W 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 0.749023 g It is concerned with disorders that can be transmitted from the parent to offspring and succeeding generation. 0 0 10.4683 10.4684 re 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 1 1 8.4684 8.4684 re All questions contained in this questionnaire are strictly confidential and will become part of your medical record. n Q n 0 0 10.4683 10.4684 re EMC endstream endobj 230 0 obj <>/Subtype/Form/Type/XObject>>stream 0 0 10.4683 10.4684 re EMC ET ET ET W (4) Tj q 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���_�? 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 Q endobj d . BT 2.414 2.9774 Td 0 0 10.4683 10.4684 re 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 223 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f endstream endobj 237 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q 1 1 8.4683 8.4684 re Age requirements may apply for some products and services offered. Q 1 1 8.4683 8.4684 re ET /Tx BMC 0.749023 g f BT f endstream endobj 192 0 obj <>/Subtype/Form/Type/XObject>>stream EMC Family History 1. 0 0 10.4683 10.4684 re BT (4) Tj 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 f 0 0 10.4684 10.4684 re Name (Last, First, M.I. 6.4205 TL 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 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 265 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream The more detail you provide, the more we can tailor our time together to meet your individual nutrition needs and goals. n f 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 1 1 8.4683 8.4684 re ET Q DO NOT SEND TO HIM. Heart disease If yes, what is the relation? 6.4205 TL 6.4205 TL 6.4205 TL n All of your answers will be confidential. 0.749023 g (4) Tj endstream endobj 291 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream g . HEALTH HISTORY QUESTIONNAIRE This questionnaire must be completed before your physical exam or before your provider can sign any activity/camp/sports forms. PDF | The development and standardization of the Women's Health Questionnaire (WHQ) is described. /ZaDb 6.6672 Tf 0.749023 g n BT NEW PATIENT HEALTH HISTORY FORM . f endstream endobj 279 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f q n /ZaDb 6.6672 Tf [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 q weightlosscenterar.com. 0 0 10.4684 10.4684 re 0 0 10.4684 10.4684 re _____ What symptoms are you having? 1 1 8.4684 8.4684 re 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. (4) Tj Download. The medical significance of tracking the family genogramcame to light with the developments in medical genetics. 6.4205 TL 1 1 8.4684 8.4684 re /ZaDb 6.6672 Tf /Tx BMC The h ealth history questionnaire is a sheet of questions asking about the patient’s health history. _____ What other topics would you like to discuss if there is time? endstream endobj 197 0 obj <>/Subtype/Form/Type/XObject>>stream By using this sample, the doctor ensures the patient's better care and treatment. /Tx BMC BT endstream endobj 273 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0.749023 g endstream endobj 239 0 obj <>/Subtype/Form/Type/XObject>>stream (circle one) Yes No Within the past 12 months, have you worried that your food would run out before … 4 0 obj ET 2.414 2.9774 Td EMC q 2.414 2.9774 Td Pre-Placement Health History Questionnaire | 3 of 5 Confidential ––– ––– 5. ET Q endstream endobj 282 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream ET endstream endobj 272 0 obj <>/Subtype/Form/Type/XObject>>stream 0.749023 g 0.749023 g endstream endobj 263 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re endstream endobj 219 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W 2.414 2.9774 Td 2.414 2.9774 Td /ZaDb 6.6672 Tf /ZaDb 6.6672 Tf 6.4205 TL Q ET (4) Tj 0.749023 g /ZaDb 6.6672 Tf /ZaDb 6.6672 Tf f f ET f (4) Tj Details. 2.414 2.9774 Td ET 0.749023 g 1 1 8.4684 8.4684 re 1 1 8.4684 8.4684 re BT BT 6.4205 TL f ET f Q /ZaDb 6.6672 Tf 2.414 2.9774 Td BT n q It is long because it is comprehensive. All responses are confidential. 2.414 2.9774 Td 0.749023 g Q Questionnaire . We really want to know you well so we can properly care for you. HEALTH HISTORY QUESTIONNAIRE Name _____ Date of Birth _____ Date Completed _____ What is the major focus of your visit? (4) Tj HEALTH HISTORY QUESTIONNAIRE This form should be completed as fully as possible by client but reviewed by medical or clinical staff. ET 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 known allergies No Known Dru. In the questionnaire the health detail of the child is given and need to mention if the child has any complication and symptom. 0.749023 g endstream endobj 258 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 1 8.4683 8.4684 re ET 6.4205 TL BT endstream endobj 260 0 obj <>/Subtype/Form/Type/XObject>>stream ET 6.4205 TL q stream 0.749023 g endstream endobj 243 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Social History Do you exercise regularly? ET 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. endstream endobj 206 0 obj <>/Subtype/Form/Type/XObject>>stream Q 6.4205 TL q q BT ): 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 … Allergies List all Prescribe. (circle one) Yes No Type of exercise? <>>> n 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 EMC 1 1 8.4683 8.4684 re endstream endobj 257 0 obj <>/Subtype/Form/Type/XObject>>stream _____ Medical History Current and Past Medical Problems 1 1 8.4684 8.4684 re 1 1 8.4683 8.4684 re /ZaDb 6.6672 Tf ET endstream endobj 196 0 obj <>/Subtype/Form/Type/XObject>>stream (4) Tj Q BT 0 0 10.4684 10.4684 re W /ZaDb 6.6672 Tf f endstream endobj 193 0 obj <>/Subtype/Form/Type/XObject>>stream A questionnaire contains a series of questions that the patient would be required to answer. 0.749023 g endstream endobj 236 0 obj <>/Subtype/Form/Type/XObject>>stream W 6.4205 TL 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 255 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f 6.4205 TL /ZaDb 6.6672 Tf q EMC 1 1 8.4684 8.4684 re endstream endobj 189 0 obj <>/Subtype/Form/Type/XObject>>stream ET 2.414 2.9774 Td n 0.749023 g EMC 0 0 10.4684 10.4684 re n 0 0 10.4684 10.4684 re ��P+((¥FM�6 f (4) Tj Q These make it easy for the doctors to know about their symptoms and problems. endstream endobj 248 0 obj <>/Subtype/Form/Type/XObject>>stream H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y endstream endobj 283 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 6.4205 TL 1 0 obj a. nd . �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 n W n 0.749023 g endstream endobj 199 0 obj <>/Subtype/Form/Type/XObject>>stream /ZaDb 6.6672 Tf 1 1 8.4684 8.4684 re Please fill in all . BT 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 0 0 10.4683 10.4684 re 0 0 10.4684 10.4684 re BT 2.414 2.9774 Td 0 0 10.4683 10.4684 re _____ Do you feel safe at home? 0 0 10.4684 10.4684 re W 1 1 8.4684 8.4684 re 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. If you are a current patient there is a shorter update form you ca n use. Health and Lifestyle Questionnaire. W n Q W W endstream endobj 251 0 obj <>/Subtype/Form/Type/XObject>>stream q 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>> QUESTIONNAIRE. 6.4205 TL 0 0 10.4684 10.4684 re The detailed history about a patient has to be furnished in this document. Name (Last, First, M.I.) endstream endobj 207 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream W endstream endobj 212 0 obj <>/Subtype/Form/Type/XObject>>stream BT ET 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 … 1 1 8.4684 8.4684 re ET 2.414 2.9774 Td W Q 0.749023 g 2.414 2.9774 Td BT 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 W 6.4205 TL q 1 1 8.4683 8.4684 re /ZaDb 6.6672 Tf All information is kept confidential. 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 2.414 2.9774 Td BT endstream endobj 213 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream f ET 6.4205 TL BT f _____ (At least 30 minutes of physical activity; Ex. 6.4205 TL 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. 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 ET (4) Tj 2.414 2.9774 Td Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. q W n 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 The purpose of this questionnaire is to know about the health history of the patients and to get an idea about his health. BT 1 1 8.4683 8.4684 re 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. W endobj (4) Tj 6.4205 TL f endstream endobj 242 0 obj <>/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. /Tx BMC endstream endobj 249 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 3 0 obj EMC EMC (4) Tj BT Name (Last, First M.I. 2.414 2.9774 Td endstream endobj 278 0 obj <>/Subtype/Form/Type/XObject>>stream W /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 295 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0 0 10.4684 10.4684 re /ZaDb 6.6672 Tf ET BT endstream endobj 231 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream pages. f n Q 6.4205 TL <> n 1 1 8.4683 8.4684 re BT _____ Age of diagnosis: _____ High cholesterol If yes, what is the relation? ): 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. ET endstream endobj 287 0 obj <>/Subtype/Form/Type/XObject>>stream From the questionnaire the doctor gets the idea from where to start the treatment and for this, the template of the pediatric questionnaire should be downloaded 2. /ZaDb 6.6672 Tf 6.4205 TL q BT (4) Tj q n 2.414 2.9774 Td Q (4) Tj f h�bbd```b``������0� Patient health history questionnaire is required to be filled by doctors whenever there is a patient coming for the first appointment. 0 0 10.4683 10.4684 re /Tx BMC Asthma, Diabetes, … /ZaDb 6.6672 Tf HEALTH HISTORY QUESTIONNAIRE. Q 0.749023 g endstream endobj 194 0 obj <>/Subtype/Form/Type/XObject>>stream q 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: _____ Q f DISCARD FORM AFTER ENTRY, USING CONFIDENTIAL RECYCLE. 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 274 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Medical genetics what other topics would you like to discuss If there is?... Form you ca n use Reason for Visit Today: ALLERGIES: List a..! € or “UNSURE” for the doctors to know you well so we can tailor our together... The purpose of this questionnaire are strictly confidential and will become part of your record... Patient history, ALLERGIES and other information are presented in different sections disorders that be... 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