HEALTH HISTORY
DO NOT ALTER THIS FORM
Patient must be 35 years or older
Must follow HIPPA guidelines
Interview must be completed in person
BIOGRAPHIC DATA (2 points)
Name (Initials):Age:Gender:Marital Status:
Date of Birth: Birthplace:
Address
Race:
Religion/Culture:
Occupation:
Insurance Coverage:
Source of Information AND Reliability:
PRESENT HEALTH OR ILLNESS
Reason for Seeking Care: (“In quotes”) (2 points)
