Medical History Questionnaire Form
ADVERTISEMENT
1
2
3Last Name:_________________
Today’s Date: _____________
University of Houston
Q-Fit Advanced Assessment - Medical History Questionnaire
All information is private and confidential
Title: ___Mr. ___Ms. ___Miss ___Mrs. ___Dr.
Gender: ___M ___F
Name (Last, First, MI)_________________________________________________________
Address ____________________________________________________________________
Number and Street
City, State
Zip
Phone (
) ______________ SSN _____-____-_____ DOB _____-____-_____
Email: _______________________________________
Age_______ yrs
Current weight _________ lbs
Current height ______ft ______in
Physician Dr.________________________ Phone (
)____________________
Address ________________________________________________________________
Number and Street
City, State
Zip
Emergency Contact
Name: ______________________ Phone:_______________ Relationship: _____________
Occupation _______________________ Employer _________________________________
Family Medical History
Father: ___Alive, age: ____yrs, General health: ____excellent ____good ____fair ____poor
____Deceased, at age: ____yrs, Cause of death: ___________________________________
Mother: ___Alive, age: ____yrs, General health: ____excellent ____good ____fair ____poor
____Deceased, at age: ____yrs, Cause of death: ___________________________________
Siblings: ___No. of brothers, ____No. of sister, Age Range________
Health problems:
If your parents, siblings, grandparents, aunts, uncles have had any of the following, please indicate
with a check mark and comment below as needed:
____High blood cholesterol
____Heart attack under age 50
____High blood pressure
____Stroke under age 50
____Diabetes
____Congenital heart disease
____Asthma/Hay fever
____Heart operations
____Glaucoma
____Leukemia/Cancer under age 60
____Obesity (20 or more lbs overweight)
Comments
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life