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Health Hx Questionnaire (Mental Health (Sexual Activity, Sexual Partners,…
Health Hx Questionnaire
Mental Health
Sexual Activity
Sexual Partners
How many times do you drink/week?
Do you smoke/use Ecigerates?
Have you ever experienced feeling depressed/have thoughts of suicide?
Do you use recreational drugs?
What is your anxiety level?
Family History
Depression/anxiety in the family?
history of sickle cell?
History of heart disease?
Is there a smoker in the family?
Diabetes?
Kidney disease?
Womens health
When was your last PAP smear?
Are you taking birth control?
When was your last menstral cycle?
Personal (history/information)
Name/DOB/Age/Year/Sexual orientation/ gender/ethnicity
Allergies
Medication? Inhaler? Epipen?
Do you have asthma?
Latex? Aspirin? Sulfa Drugs? Oral Anti-Inflammatory? Penicillin? Ibuprofen? Adhesives? Codeine? Iodine?Acetaminophen?
Seasonal? Environmental? Food?
Orthopedic History
Broken bones? fractures? If so, where?
Have you been diagnosed with bone disease?
Dislocations?/Subluxations?
Have you had any problems related to your: Hip, Neck, Spine, Shoulder, Elbow, Wrist, Hands, Knees, Ankles, Foot, Toes?
History of surgery?
Have you been diagnosed with any past concussions? If so when?
Have you every been hospitalized?