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MEDICAL HISTORY/SCREEN
Height
Feet,inches
/
What is your Occupation?
Do you work shift work?
Do you have a doctor?
Are you pregnant?
Past Health History
• • •
Other Medical Conditions
Please list previous surgeries.
SEXUAL HEALTH
Have you ever been tested for HIV or AIDS?
If yes, date?
If sexually active, methods of STD prevention or birth control?
Weight and diet habits
Weight
Were you overweight as a child
How do you feel when you eat?
After eating you feel
Do you ever skip meals?
Reasons to skip meals or overeat
• • •
Where do you eat your meals?
• • •
How often do you dine out?
• • •
You feel your appetite is
What diets have you tried?
• • •
EXERCISE
Do you exercise?
What kind of exercise do you do?
• • •
How often do you exercise?
• • •
Other Physical Activities
SUBSTANCES
Do you use tobacco products?
If yes, what kind and how much?
/
Do you drink alcohol?
If yes, what kind and how much?
/
Number of days without substance use?
Last drugs/alcohol used?
• • •
How much?
How long ago?
Do you use nicotine?
How long ago?
Anything special we need to know
FAMILY MEDICAL HISTORY (parents and siblings)
Family Medical History (parents)
• • •
Family Medical History (siblings)
• • •
Living Parents
Name, age
/
Name, age
/
Name,age
/
Name,age
/
Living Siblings
Name,age
/
Name,age
/
Name,age
/
Name,age
/
Name,age
/
Name,age
/
Name,age
/
Name,age
/
Deceased Parents
Name of Parent
Age, Cause of death
/
Name of Parent?
Age, Cause of death
/
Name of parent?
Age, Cause of death
/
Name of parent?
Age, Cause of death
/
Deceased Siblings
Name of Sibling?
Age, Cause of death
/
Name of Sibling?
Age, Cause of death
/
Name of Sibling?
Age, Cause of death
/
Name of Sibling?
Age, Cause of death
/

medical history Medical Form

Counselor Mental Health

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Published: Dec. 6, 2022, 6:24 a.m.
Doctor: Dr. History Physical
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