Patient Self-History Form - Nc Page 3

PATIENT SELF-HISTORY FORM (DHHS 4060)

Purpose:

To expedite the collection of health history information.

Instructions:

This form is to be completed by the client and reviewed by the

designated health care provider. The client is to follow the

instructions that precede each section. The form is available in

both English and Spanish. It is not a mandatory form and may be

used at the discretion of the health department.

Disposition:

This form is to be retained in accordance with the records

disposition schedule of medical records as issued by the Division

of Archives and History.

115

DHHS 4060 (01/05)

PHNPD (Review 7/07)

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Parent category: Medical