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Available Forms

Cryobank Health History Questionnaire

Family Healthcare of Fairfax, PC

Please fill as completely as you can. If not sure, leave blank.

PAST MEDICAL HISTORY:

INCLUDE DATE AND NATURE OF PROBLEM
INCLUDE DATE, OPERATION/ HOSPITALIZATION, AND REASON
INCLUDE MEDICATION, DOSE, AND FREQUENCY OF USE
INCLUDE SUBSTANCE AND REACTION
 

PERSONAL HISTORY

MARITAL HISTORY:

EDUCATION AND OCCUPATION:

 

FAMILY HISTORY

For each family member, please indicate: If they are living -- their age and health. If deceased -- the cause and age at death

List all
List all

Below, please check any conditions had by a blood relative:

 

SEXUAL AND REPRODUCTIVE HEALTH

 

HABITS

TOBACCO USE:

ALCOHOL USE:

DRUG USE:

* Required field