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6.4205 TL 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: _____ 2.414 2.9774 Td Confidential Health History Questionnaire Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. ET BT pages. H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y
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6.4205 TL 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: _____ 2.414 2.9774 Td Confidential Health History Questionnaire Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. ET BT pages. H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y
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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. W q /ZaDb 6.6672 Tf Allergies List all Prescribe. 0.749023 g BT NEW PATIENT HEALTH HISTORY FORM . QUESTIONNAIRE. ��$"F-���S��Tk"M� 0.749023 g 1 1 8.4684 8.4684 re
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0.749023 g 0 0 10.4684 10.4684 re Over the Counter (OTC) medications, including Vitamins or Herbal MEDICATIONS: Social History Marital Status: _____ Occupation: _____ Smoking Status: Never Former When did you quit? 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 ⦠Please fill out this form to the best of your ability. EMC Q HEALTH HISTORY QUESTIONNAIRE This form should be completed as fully as possible by client but reviewed by medical or clinical staff. ET a. nd . (4) Tj 1 1 8.4684 8.4684 re 6.4205 TL f 0 0 10.4683 10.4684 re n 0 0 10.4684 10.4684 re 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. Hernia, or any condition that may be aggravated by lifting weights or other physical activity q q. HEALTH-HISTORY . _____ Age of diagnosis: _____ High cholesterol If yes, what is the relation? W %PDF-1.5
��A)��!6)� 0�x���c�! ET 0.749023 g ET FREE 10+ Sample Health Questionnaire Forms in PDF | MS Word A health questionnaire is usually used to record the medical history of a patient. Q W Q n /Tx BMC 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. BT f 6.4205 TL 6.4205 TL (4) Tj
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Name of Child:_____ Date of Birth:_____ Check âYES,â âNO,â or âUNSUREâ for the following questions. ET EMC HEALTH HISTORY QUESTIONNAIRE. ET EMC
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6.4205 TL 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: _____ 2.414 2.9774 Td Confidential Health History Questionnaire Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. ET BT pages. H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y
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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. 6.4205 TL 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 ⦠f Q W H�E��}�+���N��M+��������[�J�A�����x��W�� o�U�.x-ό}���w�DTcN0��4ju�7�1O�����1q�W� )�y
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Q BT q BT (4) Tj Details. q BT The patient history, allergies and other information are presented in different sections. BT /ZaDb 6.6672 Tf Health History Questionnaire - New Patient -Gastroenterology MRN: NAME: BIRTHDATE: CSN: FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART. Patient health history questionnaire is required to be filled by doctors whenever there is a patient coming for the first appointment. /Tx BMC 6.4205 TL
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0.749023 g 0 0 10.4684 10.4684 re Over the Counter (OTC) medications, including Vitamins or Herbal MEDICATIONS: Social History Marital Status: _____ Occupation: _____ Smoking Status: Never Former When did you quit? 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 ⦠Please fill out this form to the best of your ability. EMC Q HEALTH HISTORY QUESTIONNAIRE This form should be completed as fully as possible by client but reviewed by medical or clinical staff. ET a. nd . (4) Tj 1 1 8.4684 8.4684 re 6.4205 TL f 0 0 10.4683 10.4684 re n 0 0 10.4684 10.4684 re 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. Hernia, or any condition that may be aggravated by lifting weights or other physical activity q q. HEALTH-HISTORY . _____ Age of diagnosis: _____ High cholesterol If yes, what is the relation? W %PDF-1.5
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