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OFFICE OF PROSPECTIVE HEALTH EAST CAROLINA UNIVERSITY BRODY SCHOOL OF MEDICINE BASIC HEALTH HISTORY PERSONAL Name B#:Date of Birth Home Address: City Zip Home Phone Sex:Emergency Contact Relationship
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How to fill out basic health history
How to fill out basic health history
01
Gather all relevant personal information such as full legal name, date of birth, and contact details.
02
Note down any existing medical conditions or allergies that you are aware of.
03
Record a detailed medical history, including any previous surgeries, illnesses, or hospitalizations.
04
Provide a list of current medications and dosages, including over-the-counter drugs and supplements.
05
Include information about your family medical history, any hereditary conditions, or diseases that run in your family.
06
List any known mental health issues or psychological disorders.
07
Document lifestyle habits such as smoking, alcohol consumption, and exercise routines.
08
Mention any recent or frequent travel to other countries or exposure to infectious diseases.
09
Remember to sign and date the health history form.
Who needs basic health history?
01
Anyone seeking medical treatment or care from a healthcare professional.
02
Individuals who are starting a new job and require a pre-employment medical examination.
03
Patients admitted to hospitals or outpatient clinics for a procedure or surgery.
04
Participants in clinical trials or research studies that require health information.
05
Individuals applying for medical insurance or disability benefits.
06
People with chronic illnesses or conditions who regularly visit their healthcare provider.
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What is basic health history?
Basic health history is a record of a person's past illnesses, medical conditions, surgeries, medications, allergies, and family medical history.
Who is required to file basic health history?
All individuals are required to file basic health history, especially when seeking medical treatment or participating in healthcare programs.
How to fill out basic health history?
Basic health history can be filled out by providing accurate and detailed information about personal and family medical history, current medications, allergies, surgeries, and other relevant medical information.
What is the purpose of basic health history?
The purpose of basic health history is to provide healthcare providers with essential information about a person's medical background in order to provide effective and personalized medical treatment.
What information must be reported on basic health history?
Information that must be reported on basic health history includes past illnesses, medical conditions, surgeries, medications, allergies, and family medical history.
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