Chapter 4: Health History Forms

Ask students what forms they complete when they go to the doctor. Ask them if they fill out the forms in English or in their native language. Who helps them fill out the information for the doctor?

Today you will learn how to fill out a health history form. This is a form that the doctor asks you to fill out every year to update your health history.

Review the vocabulary by pointing to the word and pronouncing it. Write a sentence on the board using the word and ask students to write a sentence about themselves.

Some possible sentences are: I have high blood pressure. I don't have high blood pressure. (Students can use this structure for asthma, arthritis, diabetes, and stomach problems.)

I take a lot of medications. I don't take any medications. I take blood pressure medication. etc.

Divide students into breakout rooms or in pairs and have them practice the words in small groups. Have them take the quiz either in pairs or individually. 

Present the Personal history form. Review each part.

Part 1: Personal information: Write the following questions on the board:

What is her first name? What is her last name? What is her address? What city does she live in? What state does she live in? What is her zip code? What is her phone number? What is her date of birth? How old is she? What is her gender? (You will need to discuss, prefer not to say. This may be a good time to talk about gender roles that students may not be familiar with.

Have the students practice answering the questions.

Part 2: Emergency information? Ask students who to call in an emergency. Ask the question, What is the emergency contact name? What is the relationship? What is the phone number?

Part 3:Medical Information: Review the information on the form. Discuss surgery and dates. 

When students are ready, have them take the quiz  in pairs or individually.

Have students get into pairs or breakout rooms and practice asking and answering questions first about Mei Ling and then about themselves. 

After students have taken the quiz, if they have a Google account, have them download a copy the health history form to fill out. If not, perhaps you can make a screenshot of the form to print for them to fill out.

Note: Students must take the quiz before trying to fill out the form.

As a further review for students who need more practice. Have them do this reading practice.

Hopefully, students will be able to fill out the most minimal information on a health history form the next time they go to the doctor.