Family Healthcare of Fairfax, PC Patient Portal

Available Forms

Adult Gyn History Cryobank Covid-19 and Health Screening Form Cryobank Health History Questionnaire Cryobank Patient Registration Form Financial Policy Health History Questionnaire HIPAA Form Immigration New Patient Registration Form Immigration Physical - Patient Health History Questionnaire Influenza Vaccine Consent Form New Patient Registration Form Patient Pre-Visit Covid-19 Screening Physical Exam Form

Health History Questionnaire

Family Healthcare of Fairfax, PC

Please fill as completely as you can. If not sure, leave blank.

Name and Age *

Date of Birth *

Today's Date *

PAST MEDICAL HISTORY:

List any chronic/ severe or recurrent illnesses:

INCLUDE DATE AND NATURE OF PROBLEM

List any Hospitalizations/ Surgeries:

INCLUDE DATE, OPERATION/ HOSPITALIZATION, AND REASON

List All Medications - prescription and non-prescription which you take regularly:

INCLUDE MEDICATION, DOSE, AND FREQUENCY OF USE

List any medications and substances to which you are allergic:

INCLUDE SUBSTANCE AND REACTION

CHECK ANY THAT YOU HAVE HAD: *

IMMUNIZATIONS/ WELL CARE:

Check those that apply, then in the space below indicate the Date you last received such medical care.

Names and Dates of Immunizations and Well Care

PERSONAL HISTORY

MARITAL HISTORY:

My current status is:

With whom do you now live?

RELIGION - Religious Preference:

HAVE YOU BEEN IN THE MILITARY?

EDUCATION AND OCCUPATION:

Highest education achieved:

Present position/ employment:

Previous jobs?

Exposure to toxins at work?

If exposed to toxins, please list the type:

FAMILY HISTORY

For each family member, please indicate: If they are living -- their age and health. If deceased -- the cause and age at death

Father

Mother

Brother/ Sister

List all

Husband/Wife

Son/Daughter

List all

Grandmother

Grandfather

Grandmother

Grandfather

Please list any other diseases that run in your family:

Below, please check any conditions had by a blood relative:

Family History of Conditions:

If any of the above boxes are checked, please indicate which condition and which blood relative has had such condition:

SEXUAL AND REPRODUCTIVE HEALTH

QUESTIONS FOR WOMEN ONLY:

MENSTRUATION:

Include age periods began, cycle length, and period length

Date of last menstrual period:

Flow:

Discomfort:

Pre- Menstrual Syndrome

PREGNANCIES:

Include all that apply: Total number, full term, premature, stillbirths, miscarriages, abortions, and tubal pregnancy:

List any pregnancy complications:

QUESTIONS FOR BOTH MEN AND WOMEN:

What kind of birth control do you and/or your partner use?

Have you had concerns about fertility? What kinds of concerns?

How would you describe your sexual orientation?

QUESTIONS FOR MEN ONLY:

Have you had problems with:

Prostate?

Impotence?

Lump on testis?

HABITS

DIET & EXERCISE:

Do you follow a special diet?

Current Weight:

Desired Weight:

Weight 1 year ago:

What kind of exercise do you do?

TOBACCO USE:

How much do you smoke?

None

Regularly

If regularly, how much per day?

Have you quit smoking?

Yes

If yes, when?

Do you use any other tobacco?

Yes

If yes, what type?

ALCOHOL USE:

Do you drink alcohol?

Yes

Have you had problems with your drinking?

Yes

If yes, please explain:

What is your usual drinking pattern?

* Required field