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 (City/State only)
Race:
Religion/Culture: None is NOT an answer!
Occupation:
Insurance Coverage: Only need to know if they have health insurance – do not need policy name or number
Source of Information AND Reliability: ex: Patient and appears to be reliable
PRESENT HEALTH OR ILLNESS
Reason for Seeking Care: (“In quotes”) (2 points)
“I am helping (insert your name here) with their school project”
