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HEALTH HISTORY FORM - ADULT Please Print Patient s Last name First Middle Today s date / Birth date HRN ALLERGIES CURRENT MEDICATIONS/DOSAGES PAST SURGERIES/HOSPITALIZATIONS Have you ever had or are currently having YES NO ANEMIA ARTHRITIS ASTHMA BREAST DISEASE BRONCHITIS OR PNEUMONIA CANCER DENTAL PROBLEMS DIABETES MELLITUS DRINKING OR DRUG PROBLEMS EMPHYSEMA EPILEPSY/SEIZURE DISORDERS GERMAN MEASLES GLAUCOMA OR CATARACTS GOUT HAYFEVER/SEASONAL ALLERGIES HEARING PROBLEMS HEART DISEASE...
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What is health history form?
Health history form is a document that collects information about an individual's medical background, including any illnesses, allergies, medications, and previous surgeries.
Who is required to file health history form?
Health history form must be filled out by individuals seeking medical treatment or care, as well as by individuals participating in certain activities such as sports or travel.
How to fill out health history form?
To fill out a health history form, one must provide accurate and detailed information about their medical history, including any current medications, allergies, surgeries, and illnesses.
What is the purpose of health history form?
The purpose of a health history form is to provide healthcare professionals with important information about an individual's medical background, which can help guide treatment and ensure patient safety.
What information must be reported on health history form?
Information that must be reported on a health history form includes current medications, allergies, past surgeries, medical conditions, and any family history of illness.
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