Child And Pediatric Health History Form Page 3
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4MRN:
UNIVERSITY OF MICHIGAN HOSPITALS & HEALTH CENTERS
NAME:
Gastroenterology
BIRTHDATE:
Health History Questionnaire - New Patient
-Gastroenterology
CSN:
☐Yes
☐No
☐Not currently
Are you sexually active?
☐Male
☐Female
☐Both
If yes, is/are your partner(s):
Type of birth control/protection currently used:
☐Not having sex (Abstinence) ☐Condom
☐Injection
☐IUD (Intrauterine Device)
☐Oral Contraceptives (Pill)
☐Patch
☐Post-menopausal
☐None
☐Other (specify): ___________
☐Yes
☐No
Do you use drugs?
If you use drugs, how many times per week? _________________
What type(s) of drugs do you use? _____________________________________________________________________
Check one of the following about smoking tobacco:
☐Never smoked
☐Former smoker
☐Smoke some days
☐Smoke every day
☐Exposed to second hand smoke
If you smoke or used to smoke, how many packs do/did you smoke per day?
_________________________
How many years did you smoke/have you smoked?
_________________________
If you quit, when did you quit?
_________________________
Do you use “smokeless tobacco”? (Select one below)
☐Former user
☐Current user
☐Never used
If you quit, when did you quit?
_________________________
☐Yes
☐No
Are you ready to quit smoking and / or using smokeless tobacco?
FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART.
DISCARD FORM AFTER ENTRY, USING CONFIDENTIAL RECYCLE. DO NOT SEND TO HIM.
Page 3 of 4
Health History Questionnaire - New Patient
VER: A/12
50-10079
Do Not File
HIM: 08/12
- Gastroenterology
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