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Health Care Consumer QuestionnairePatient Name
_____________________________
DOB
____/____/________
Date
____/____/________
In order to best serve yourmedical needs, we ask that you complete the following questionnaire as completely as possible. The
HealthCare Consumer (HCC) - Health Care Provider (HCP)
relationship is a privileged relationship built on trust and honesty. By completing and signing this form, you acknowledge that you understand that any intentionally false informationmay seriously and adversely affect your health.
Patient NameGender
M
F
Date of Birth
(
MM/DD/YYYY
Social Security Number Reason for Visit
If the person completing this form is not the patient, please write your name, your relationshipto the patient, and why the patient is unable to complete the form.
NameRelationship to PatientReason
Health Care Consumer’s Address Phone
HomeWorkCell
Emergency Contact
(
Address and Phone)
HomeWorkCell
Insurance InformationPhonePolicy #Additional, or SecondaryInsurance CompanyPolicy #
MB & RR 2008e-medtools.com
The information on this page wasreviewedwith the patient
HCC
Initials ____
HCP
Initials _____
1
Haveyou designated a Durable Power ofAttorney for Health Care?
Yes
No
If yes, please provide a copy for your health care provider.
Do you have any religious or cultural beliefs that may impactyour health care?
If yes,describe
Yes
No
I best learn newinformation by:
Verbal Instruction
Written Instruction
Handouts
Pictures
Level education completed
<6
th
grade
6
th
– 9
th
grade
12
th
grade
1-4years college
>4 years college
I understand Englishwell
Yes
No
If NO, please specify the language you prefer
Health Care Consumer QuestionnairePatient Name
_____________________________
DOB
____/____/________
Date
____/____/________
Names and Phone Numbers for Health Care Providers (HCPs) from whom you are currently receivingcare (or have seen within the past 12 months), or fromwhomyou have received prescriptions.
Contact #Contact #Contact #Contact #Contact #Contact #
Please list all of the medicationsyouare taking. Include overthe counter medications, herbs &vitamins.
Medication NameDoseLast takenMedication NameDoseLast taken
Please list and describe allergic reactionsyou have had to food, medications or insect stings.
Check if you areyou allergic to
Shellfish ___________
IV Contrast Dye __________
Penicillins
__________ Please list other
Food, Medication or Insect AllergiesDescribe your reaction
Please list your occupations. Include the length of time you performed in that role, and describeyourwork responsibilities in that occupation
. (Include military experience.)OccupationStart Date Stop Date Responsibilities
MB & RR 2008e-medtools.com
The information on this page wasreviewedwith the patient
HCC
Initials ____
HCP
Initials _____
2
Health Care Consumer QuestionnairePatient Name
_____________________________
DOB
____/____/________
Date
____/____/________
Haveyou ever been exposed to knowncancer causing agents or inhalation hazards?
Yes
No
Examples: asbestos, paints, aniline dyes, chemicals,silica, etc. AgentExposure time Problems related to exposure
Please describeyour hobbies.Haveyou traveled, in the past 1 year?
Yes
NoTravel destinations OUTSIDE the United StatesDates spentat this destinationTravel destinations INSIDE the United StatesDates spentat this destinationExercise History
Do you exercise?
Yes
NoIfyes, describe how long and howoftenyou exercise
on average each week
History of Falls
In the past 12 months, have you fallen?
Yes
No
If yes, how many times?
If yes, haveyou ever brokenbones, or sustained an injury, as a result of falling?
Yes
NoVaccination History
Haveyou ever hadany of the following vaccinations?
VaccineDate of last vaccinationInfluenza
Yes
No
Pneumonia
Yes
No
Tetanus
Yes
No
BCG
Yes
No
Varicella
Yes
No
HPV (Gardasil)
Yes
No
MB & RR 2008e-medtools.com
The information on this page wasreviewedwith the patient
HCC
Initials ____
HCP
Initials _____
3
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