A sample Depo-Provera interval history form in English and Spanish.
- IntHistDepoEngSpan.doc (36 KB)
Adult health history qustionnaire with a number of social and behavior related questions.
- AdultHealthHistoryQ.pdf (508.01 KB)
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.
This questionnaire may be used as part of the review of systemswith patients. The clinician might begin, "I need to ask a fewshort questions about your sexual health in order to be thoroughin providing your medical care."
- p4401.pdf (39.6 KB)
A Spanish translation of the Adult Medical History Form.
- HistoriaMedica.doc (62 KB)
A Spanish version of the Adult Medical History Form.
- HISTORIADESALUDDELADULTO.doc (60 KB)
A sample oral contraceptive interval history form in English and Spanish.
- IntHisOCSEngSpan.doc (41 KB)
A Spanish translation of the 1-page sample social history form.
- HistoriaSocial.doc (35 KB)