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

Cryobank 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: *

PERSONAL HISTORY

MARITAL HISTORY:

My current status is:

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

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? *

If other, please describe

Gender Identity *

Additional category gender or other description *

HABITS

TOBACCO USE:

How much do you smoke? *

None

Regularly

If regularly, how much per day?

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?

DRUG USE:

DO YOU USE ANY ILLICIT OR STREET DRUGS? IF YES, PLEASE EXPLAIN. *

* Required field