360infusioncenter.com - Health History Questionnaire

PATIENT HISTORY
Date Today:

MonthDayYear
Date
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Name

First NameMILast Name
Gender

YesNo
Date

MonthDayYear
Date
Marital Status

SingleMarriedMale PartnerFemale PartnerSeparatedDivorcedWidowedNever Married
Employment:

RetiredFull- TimePart-TimeUnemployedSelf EmployedMilitaryHomemaker
Other:
Religion:
Living With:

AloneSpouseSignificant OtherFamilyFriends
Travel:

None in last six monthsTravels to South AfricaTravels to EuropeTravels to AsiaTravels to Africa
Occupational Exposure:

NoneToxic ChemicalsNoise ExposureInfectious AgentsRepetitive Physical Stress
Domestic Violence:

NoneHistory in PastHave Restraining OrdeFeels unsafe at homeHave safety plan
PERSONAL HEALTH HISTORY
Previous or referring doctor:
Date of last physical exam:

MonthDayYear
Date
Childhood illness:

MeaslesMumpsRubellaChickenpoxRheumatic FeverPolio
Immunizations and dates:

TetanusHepatitisInfluenzaPneumoniaChickenpoxMMR Measles, Mumps, Rubella
List any medical problems that other doctors have diagnosed:

Laboratory Tests Completed:

Type Diagnostic /Imaging Completed:

Surgeries

Other hospitalizations

PATIENT HISTORY