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ADMIN USE ONLY: Referred or brought in by: ___ Inf. Consent signed Y N Turned in to office: Y N EZ Facility: Y NI Contact: Y HEALTH HISTORY and LIFESTYLE QUESTIONNAIRE SECTION I (General Information)

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How to fill out health history and lifestyle

01

Gather all necessary information such as current and past medical conditions, surgeries, allergies, medications, and family medical history.

02

Include lifestyle factors such as diet, exercise, smoking, alcohol consumption, and stress levels.

03

Fill out the health history and lifestyle forms accurately and honestly, ensuring to update them regularly as needed.

Who needs health history and lifestyle?

01

Healthcare providers including doctors, nurses, and specialists use health history and lifestyle information to provide appropriate care and make treatment decisions.

02

Insurance companies may require this information to determine coverage and calculate risk factors.

03

Individuals themselves can benefit from having a complete health history and lifestyle record for personal reference and future medical visits.

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What is health history and lifestyle?

Health history and lifestyle is a document that records an individual's medical history, habits, and behaviors that may affect their overall health.

Who is required to file health history and lifestyle?

Anyone seeking medical care or applying for medical insurance may be required to file health history and lifestyle.

How to fill out health history and lifestyle?

Health history and lifestyle forms can be filled out either electronically or manually, providing accurate and detailed information about past medical conditions, medications, and lifestyle choices.

What is the purpose of health history and lifestyle?

The purpose of health history and lifestyle is to provide healthcare providers with crucial information about a patient's health background, enabling them to make informed decisions about treatment and care.

What information must be reported on health history and lifestyle?

Information that must be reported on health history and lifestyle includes medical conditions, surgeries, medications, allergies, family history of illnesses, smoking and drinking habits, and exercise routines.

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