directionsRUA-NR302-HealthHistoryDocumentation.docx

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”