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PRE-REGISTRATION HEALTH HISTORY QUESTIONNAIRE |
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Personal Information: |
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Date: |
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Full Name:
(First , Middle, Last) |
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Birth Date: |
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SSN # (optional): |
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Address 1: |
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Address 2: |
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City, State, ZIP |
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Phone Number: |
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Family Physician: |
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Age: |
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Type of Insurance: |
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PLEASE LIST ANY
SIGNIFICANT FAMILY HISTORY OF HEART DISEASE:
(Parents, Siblings, Aunts, and Uncles) |
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1:
2:
3:
4: |
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PAST MEDICAL AND SURGICAL HISTORY PLEASE LIST ANY MEDICAL
PROBLEMS YOU ARE CURRENTLY BEING TREATED FOR OR HAVE BEEN
TREATED FOR IN THE PAST: |
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1:
2:
3:
4:
5:
6:
7:
8:
9:
10: |
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PLEASE LIST ANY SURGICAL
PROCEDURES YOU HAVE UNDERGONE: |
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1:
2:
3:
4:
5: |
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PLEASE LIST ANY CHILDHOOD DISEASES (IE: RHEUMATIC HEART DISEASE,
SCARLET FEVER): |
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1:
2: |
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DO YOU DRINK
ALCOHOL? |
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NEVER
SOCIALLY QUIT
IF S0:
DRINKS PER DAY
# OF YEARS |
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MEDICATIONS CURRENTLY TAKING: (DRUG, DOSE, AND FREQUENCY) |
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1: 2:
3: 4:
5: 6:
7: 8:
9:
10: |
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DO
YOU SMOKE? |
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YES
NO
QUIT
IF YES:
PACKS PER DAY
# OF YEARS
IF QUIT:
# OF PACKS PER DAY
# OF YEARS QUIT |
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ARE YOU ON A SPECIAL DIET? |
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YES
NO
IF YES WHAT DIET:
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PHYSICAL ACTIVITY |
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1:
2: |
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GYN HISTORY |
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DO YOU DRINK CAFFEINE? |
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YES NO
IF YES HOW MANY DRINKS PER DAY:
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LIST ALLERGIES: |
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1:
2:
3:
4:
5: |
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YOUR NAME: |
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