Maryland healthy kids program medical/family history questionnaire 2/06 patient name: date of birth: sex: (circle) male female form completed by: today’s date relationship: pregnancy and birth history psychosocial history family history medical history has anyone in the family (parents, grand-parents. In this survey, a “healthy diet” means eating a wide variety of foods which contain plenty of fiber and are low in fat, salt, and sugar worksite eating habits 1 how important do you feel other people’s support is in helping you eat a healthy diet not important very important 2 how often do any of your co-workers: a. Staying healthy assessment questionnaires (sha) age and language-specific sha questionnaires can be opened by clicking the links below currently all questionnaires are available in a pdf format. Health history questionnaires may also include questions regarding a respondent’s family medical history, meaning history of alcohol or substance use and abuse, hereditary diseases (diseases that run in the family) or diseases that may have caused hospitalization or death of any family member, and family traditions or culture which may have affected the patient’s overall present health status.
Family practice/internal medicine health history questionnaire your answers on this form will help your health care provider better understand your medical concerns and conditions if you are uncomfortable with any question, do not answer it if you cannot remember specific details, please approximate. In a health questionnaire, the respondent is asked to answer a few questions regarding his/her overall health condition, health history including previous or current illnesses and medications or treatments, alcohol consumption and cigarette use, physical activity and diet, as well as family medical history.
Initial history questionnaire household please list all those living in the child’s home relationship birth health name to child date problems biological family history dk = don’t know have any family members had the following childhood hearing loss yes no dk who comments nasal allergies yes no dk who comments. Staying healthy assessment questionnaires (sha) age and language-specific sha questionnaires can be opened by clicking the links below currently all questionnaires are available in a pdf format in the near future, the questionnaires will be available as a fillable pdf forms. 1 how would you describe your family’s current state of health 2 what are you doing to promote health 3 are there any habits that can be detrimental to you or your families health.
Tell your family members that they can photocopy blank questionnaires and send them to other family members 5 try to get all the forms back keep in mind that not everyone will fill out all the questions because of the sensitive nature of health information 6. For more health and wellness information, visit wwwhealthywomenorg your family medical history questionnaire even.
Family assessment questionnaire ii print name: date: 1 have you experienced any of the following during the past two years (check all that apply) marital reconciliation divorce separation from spouse or partner fired from job change in health of a family member.
Medical examination services survey template offers questions to evaluate the desirability of medical examination features and customer attitudes of current services this sample can be edited by the survey maker according to the required details about the medical examination.
Instructions for using the family health history questionnaire: 1 photocopy the questionnaire on the opposite side of this sheet for you and your family members 2 fill out one copy for yourself 3 send out the other copies to family members along with a letter explaining why you sent it. A healthy family: questionnaire what types of drinks do you usually have during the day and night i will usually have one bottle of soda half way through the day.
47 questions physician practices survey template offers questions for evaluation of hospital and the services provided this sample can be edited by the survey maker according to the required details about hospitals and their services. Healthy kids, healthy families® evaluation questionnaire information provided to grantee: organization funded project/program title grant amount project information (entire open ended question field from application) section 1 outcomes 1. A healthy family: questionnaire what types of drinks do you usually have during the day and night i will usually have one bottle of soda half way through the day the rest of the day is water how often does your family seek dental care my children and i visit the dentist every six months for a cleaning.