Child And Pediatric Health History Form Page 2
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4MRN:
UNIVERSITY OF MICHIGAN HOSPITALS & HEALTH CENTERS
NAME:
Gastroenterology
BIRTHDATE:
Health History Questionnaire - New Patient
-Gastroenterology
CSN:
Family History
Check below to report problems your family members have had. Please state the age when they had the problem if you
know it.
☐I was adopted so I do not know my family history.
Mother
Father
Sister
Brother
Son
Daughter
Other (list)
Alcohol abuse
Breast cancer
Cancer
Celiac disease
Colon cancer
Colon polyps
COPD (lung disease)
Cystic fibrosis
Diabetes
Heart attack
High cholesterol
Hypertension
Inflammatory bowel
disease
Irritable bowel
syndrome
Kidney disease
Liver disease
Other (specify)
Alive (Yes, No, or N/A=
Not Applicable
Social History
☐ Divorced
☐Legally Separated
☐Married
☐Significant other
☐Single
Marital Status:
☐Widowed
☐Unknown
☐Other (specify):____________
What is your current occupation? ______________________________________________________________________
☐Yes
☐No
Do you ever drink alcohol?
If yes, please indicate the quantity per week of each:
Glasses of wine _____
Cans/bottles of beer _____
Shots of liquor _____
Drinks containing 0.5 oz of alcohol _____
FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART.
DISCARD FORM AFTER ENTRY, USING CONFIDENTIAL RECYCLE. DO NOT SEND TO HIM.
Page 2 of 4
Health History Questionnaire - New Patient
VER: A/12
50-10079
Do Not File
HIM: 08/12
- Gastroenterology
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