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Personal Health Profile Essay

386 words - 2 pages

Kaiser Foundation Health Plan of the Northwest  Kaiser Foundation Hospitals

HR #: DOB: Clinician:

Personal Health Profile
Medications (Prescription and over-the-counter drugs) Drug Names Strength Frequency

Medical Office: Occupation: Medication Allergies Drug


Major Surgeries or Injuries (Include year if known)

Other Hospitalizations (Include year)

Have you been treated for any of the following? Yes No Yes No Yes   Diabetes   High Cholesterol    High Blood Pressure   Heart Disease    Thyroid Disease   Lung Disease   Other (Explain) Does your mother, father, sister or brother have any of the ...view middle of the document...

Mgmt  Stress Mgmt  B.S.E.  T.S.E.  Ear Care  Other:_______________________ Lab: (Circle) CBC Chol T4/TSH Clinician’s Signature: X
12803 6/09 HAP Administration/MPO




DT Occult Blood x 3 Other: Date: ___

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