Health History Questionnaire Page 2
Before filling out any questionnaires, please print and sign the forms under the Patient Forms tab at http://www.drjonesbailey.com. Bring them to your next appointment with Dr. Alise Jones-Bailey. Thank you.
Patient Name: *
Your answer
Date of Birth
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PREVENTIVE SERVICES ASSESSMENT: Flex Sigmoidoscopy/Colonoscopy
Rectal Exam
Flu Shot
Tetanus Shot
Cholesterol Check
Pneumovax (Pneumonia) Shot
EXERCISE ASSESSMENT: In a week how many times do you engage in aerobic exercise for 30 minutes or more?
How often do you exercise to build your strength, such as sit-ups, push-ups or weight training?
SEXUAL HEALTH ASSESSMENT: Are you emotionally and physically satisfied with your sexuality?
In your lifetime, have you only engaged in heterosexual activity?
On average, how often do you have sexual intercourse?
Your answer
STRESS ASSESSMENT: Please choose what you perceive is your stress level.
HORMONAL QUESTION DHEA: Check all that apply.
HORMONAL QUESTIONS SLEEP/MELATONIN: Check all that apply.
FOR WOMEN ONLY: Pap Test
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Mammogram
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Hormones checked
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Bone Density Test
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FOR MEN ONLY: Prostate Exam
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Testicular Exam
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Hormones checked
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PSA Check
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