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Comprehensive Health History Form
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Comprehensive Health History Form
Instructions
Please fill out this form with accurate details about your health history. This information will help your healthcare provider better understand your needs and provide personalized care.
Section 1: Personal Information
Name
*
Age:
*
Marital Status:
*
Single
Married
Divorced
Widowed
Occupation:
Primary Language(s):
Section 2: Medical History
1. Do you have any of the following medical conditions? (Check all that apply)
Diabetes
High blood pressure
Heart disease
Thyroid disorders
Asthma or respiratory issues
Mental health concerns (e.g., anxiety, depression)
Other
Other (please specify):
2. Have you ever been hospitalized?
Yes
No
Please provide details:
3. Are you currently taking any medications or supplements?
Yes
No
List them:
4. Do you have any allergies (e.g., food, medication, environmental)?
Yes
No
Please specify:
Section 3: Family History
5. Does anyone in your family have a history of the following?
Yes
No
Diabetes:
Yes
No
Heart disease:
Yes
No
Cancer:
Yes
No
Mental health disorders:
Yes
No
Other (please specify):
Please specify:
Section 4: Reproductive Health
6. Have you experienced any of the following?
Yes
No
Irregular menstrual cycles:
Yes
No
Menopause symptoms (e.g., hot flashes):
Yes
No
History of pregnancy complications:
7. Are you currently using contraception?
Yes
No
If yes, what method?
8. Do you plan to have more children?
Yes
No
Undecided
Section 5: Lifestyle and Social Factors
9. Do you smoke or use tobacco?
Yes
No
10. Do you consume alcohol?
Yes
No
11. How often do you exercise?
Rarely
Sometimes
Regularly
12. Do cultural or family expectations impact your health decisions?
Yes
No
13. What is your primary source of stress?
Work
Family
Financial
Other
Other:
Section 6: Current Concerns
14. What are your primary health concerns right now?
15. Are there any specific health goals you would like to achieve?
Interpretation of Your Results:
Comprehensive Health Awareness: If you have checked multiple conditions or concerns, it’s essential to schedule a consultation to develop a personalized care plan.
Reproductive or Lifestyle Concerns: Specific support is available for reproductive health, stress management, or lifestyle changes.
Cultural and Family Influences: If cultural or family expectations affect your health decisions, expert guidance can help balance personal and societal needs.
What’s Next?
If your responses highlight significant health concerns or areas where you need support, the Zan Center provides culturally sensitive and comprehensive care tailored to Pakistani women.
Disclaimer: This form is a tool for gathering information. Please consult a healthcare provider for personalized advice and treatment. This scal is a general modified guide tool quationares for Pakistani populations.
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