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Health History Forms
EOH Screening Questions for the Primary Care Setting
3 simple environmmental/occupational screening questions for the primary care provider. English and Spanish. MCN, 2007.
Surgeon General's Family Health History Tool
The U.S. Department of Health and Human Services has released an updated and improved version of the Surgeon General's internet-based family health history tool. The new tool makes it easier for patients to assemble and share family health history and can also help practitioners make better use of health history information. For more detailed information about the new tool, please visit the website listed.
Brief Sex History Questionnaire
This questionnaire may be used as part of the review of systems with patients. The clinician might begin, "I need to ask a few short questions about your sexual health in order to be thorough in providing your medical care."
- P4401.pdf( 405.53 Kb )
Adult Medical History Form2-SPANISH
A Spanish translation of the Adult Medical History Form.
- Historia Medica.doc( 634.88 Kb )
Adult Medical History Form1-SPANISH
A Spanish version of the Adult Medical History Form.
- Historiadesaluddeladulto.doc( 614.40 Kb )
Oral Contraceptive Interval History Form
A sample oral contraceptive interval history form in English and Spanish.
- Int His Ocs Eng Span.doc( 419.84 Kb )
Social History Form-SPANISH
A Spanish translation of the 1-page sample social history form.
- Historia Social.doc( 358.40 Kb )
Depo-Provera Interval History Form
A sample Depo-Provera interval history form in English and Spanish.
- Int Hist Depo Eng Span.doc( 368.64 Kb )
Adult Health History Questionnaire
Adult health history qustionnaire with a number of social and behavior related questions.
- Adult Health History Q.pdf( 5,202.04 Kb )