Gainesville Family Practice
GAINESVILLE FAMILY PRACTICEPERSONAL HEALTH HISTORYName: _____________________________________________Date: __________________________________PLEASE CHECK EITHER: Y or N (please explain any yes answers)PAST HISTORYChildhood (infancy through teens)Adult (age 20 to present)Serious Illness? Y N___________________________Serious Illness? Y N _______________________Surgery? Y N___________________________Surgery? Y N _______________________Hospitalizations? Y N _________________________Hospitalizations? Y N______________________Allergies? Y N __________________________Allergies? Y N _______________________FAMILY HISTORY (Parents, Siblings, Grandparents, Aunts, Uncles)Heart Disease? Y NDiabetes? Y NCancer? Y NHigh Blood Pressure? Y NStroke? Y NDepression? Y NSYSTEM REVIEWRespiratory TractChronic cough? Y NCough Blood? Y NEasily short of breath? Y NSinus trouble? Y NAllergy Shots? Y NChest Pain? Y NHeart and Blood VesselsChest pain? Y NPrior Heart Attack? Y NLeg pain with walking? Y NPalpitations? Y NFluid in feet? Y NGastrointestinal TractHeartburn? Y NUlcers? Y NHiatal Hernia? Y NChronic nausea? Y NCramping? Y NPoor Appetite? Y NChronic diarrhea? Y NBlood in stools? Y NPain in abdomen? Y NChange in stools? Y NSkins and NailsChronic rash? Y NNew moles? Y NFrequent sun exposure? Y NNeurologic SystemFrequent headaches? Y NMigraines? Y NNumbness? Y NFainting spells? Y NDouble vision? Y NSeizures in past? Y NSkeletal SystemJoint pains? Y NBroken bones? Y NSprained joints? Y NBack pain? Y NArthritis? Y NQuestions for MENPainful urination? Y NDifficult urination? Y NBlood in urine? Y NDischarge from penis? Y NNighttime urination? Y N(if yes, how many times per night?) _________Sexual difficulty? Y NPLEASE TURN PAGE AND COMPLETE BACK SIDE Questions for WOMENPainful urination? Y NDifficult urination? Y NPainful menses? Y NIrregular menses? Y NBirth Control Pills? Y NNumber of Pregnancies? ___________Number of children? _________Vaginal Discharge? Y NDate of last PAP? _________________Age of onset of menses? ______Age at onset of Menopause? _______Hot flashes? Y NSexual difficulties? Y NUterus removed? Y NUterus removed? Y NGeneral QuestionsWeight loss? Y NWeight gain? Y NNo interest in eating? Y NDifficulty sleeping? Y NAlways tired? Y NAlways feel cold? Y NWhat was your highest weight? ___________________________ When? _________________________________OCCUPATIONAL HISTORYCurrent occupation? ____________________________________How long? _____________________________Previous occupations? _______________________________________________________________________________Any job-related injury? Y NAny chemical or fumes exposure? Y NAny job disability? Y NSOCIAL HISTORYHabitsSmoker? Y NHow much? ___________When started? ___________When stopped? _____________Do you drink alcohol? Y N If yes, (Please circle): Beer Wine Liquor CordialsPlease circle the level of alcohol consumption:None Occasional Weekends Daily HeavyHave you used illegal drugs? Y N Have you had a sexually transmitted disease? Y NDo you think you may have any activity that puts you at risk of HIV/AIDS? Y NIS THERE ANY ADDITIONAL HEALTH HISTORY? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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