SSN:



SSN: FORMTEXT ?????Name (Last, First, M.I.): FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX FDOB: FORMTEXT ?????Marital status: FORMCHECKBOX Single FORMCHECKBOX Partnered FORMCHECKBOX Married FORMCHECKBOX Separated FORMCHECKBOX Divorced FORMCHECKBOX WidowedPrevious or referring doctor: FORMTEXT ?????Date of last physical exam: FORMTEXT ?????PERSONAL HEALTH HISTORYChildhood illness: Measles Mumps Rubella Chickenpox Rheumatic Fever PolioImmunizations and dates: FORMCHECKBOX Tetanus FORMTEXT ????? FORMCHECKBOX Pneumonia FORMTEXT ????? FORMCHECKBOX Hepatitis FORMTEXT ????? FORMCHECKBOX Chickenpox FORMTEXT ????? FORMCHECKBOX Influenza FORMTEXT ????? FORMCHECKBOX MMR Measles, Mumps, Rubella FORMTEXT ?????List any medical problems that other doctors have diagnosed FORMTEXT ?????SurgeriesYearReasonHospital FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other hospitalizationsYearReasonHospital FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Have you ever had a blood transfusion? FORMCHECKBOX Yes FORMCHECKBOX NoList your prescribed drugs and over-the-counter drugs, such as vitamins and inhalersName the DrugStrengthFrequency Taken FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Allergies to medicationsName the DrugReaction You Had FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????HEALTH HABITS AND PERSONAL SAFETYAll questions contained in this questionnaire are optional and will be kept strictly confidential.Exercise FORMCHECKBOX Sedentary (No exercise) FORMCHECKBOX Mild exercise (i.e., climb stairs, walk 3 blocks, golf) FORMCHECKBOX Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) FORMCHECKBOX Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)DietAre you dieting? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, are you on a physician prescribed medical diet? FORMCHECKBOX Yes FORMCHECKBOX No# of meals you eat in an average day? FORMTEXT ?????Rank salt intake FORMCHECKBOX Hi FORMCHECKBOX Med FORMCHECKBOX LowRank fat intake FORMCHECKBOX Hi FORMCHECKBOX Med FORMCHECKBOX LowCaffeine None FORMCHECKBOX Coffee FORMCHECKBOX Tea FORMCHECKBOX Cola# of cups/cans per day? FORMTEXT ?????AlcoholDo you drink alcohol? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what kind? FORMTEXT ?????How many drinks per week? FORMTEXT ?????Are you concerned about the amount you drink? FORMCHECKBOX Yes FORMCHECKBOX NoHave you considered stopping? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever experienced blackouts? FORMCHECKBOX Yes FORMCHECKBOX NoAre you prone to “binge” drinking? FORMCHECKBOX Yes FORMCHECKBOX NoDo you drive after drinking? FORMCHECKBOX Yes FORMCHECKBOX NoTobaccoDo you use tobacco? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Cigarettes – pks./day FORMTEXT ????? FORMCHECKBOX Chew - #/day FORMTEXT ????? FORMCHECKBOX Pipe - #/day FORMTEXT ????? FORMCHECKBOX Cigars - #/day FORMTEXT ????? FORMCHECKBOX # of years FORMTEXT ????? FORMCHECKBOX Or year quit FORMTEXT ?????DrugsDo you currently use recreational or street drugs? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever given yourself street drugs with a needle? FORMCHECKBOX Yes FORMCHECKBOX NoSexAre you sexually active? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, are you trying for a pregnancy? FORMCHECKBOX Yes FORMCHECKBOX NoIf not trying for a pregnancy list contraceptive or barrier method used: FORMTEXT ?????Any discomfort with intercourse? FORMCHECKBOX Yes FORMCHECKBOX NoIllness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness? FORMCHECKBOX Yes FORMCHECKBOX NoPersonal SafetyDo you live alone? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have frequent falls? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have vision or hearing loss? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have an Advance Directive and/or Living Will? FORMCHECKBOX Yes FORMCHECKBOX NoWould you like information on the preparation of these? FORMCHECKBOX Yes FORMCHECKBOX NoPhysical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider? FORMCHECKBOX Yes FORMCHECKBOX NoFAMILY HEALTH HISTORYAgeSignificant Health ProblemsAgeSignificant Health ProblemsFather FORMTEXT ????? FORMTEXT ?????Children FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ?????Mother FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ?????Sibling FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ?????GrandmotherMaternal FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ?????GrandfatherMaternal FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ?????GrandmotherPaternal FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ?????GrandfatherPaternal FORMTEXT ????? FORMTEXT ?????MENTAL HEALTHIs stress a major problem for you? FORMCHECKBOX Yes FORMCHECKBOX NoDo you feel depressed? FORMCHECKBOX Yes FORMCHECKBOX NoDo you panic when stressed? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have problems with eating or your appetite? FORMCHECKBOX Yes FORMCHECKBOX NoDo you cry frequently? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever attempted suicide? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever seriously thought about hurting yourself? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have trouble sleeping? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been to a counselor? FORMCHECKBOX Yes FORMCHECKBOX NoWOMEN ONLYAge at onset of menstruation: FORMTEXT ?????Date of last menstruation: FORMTEXT ?????Period every FORMTEXT ????? daysHeavy periods, irregularity, spotting, pain, or discharge? FORMCHECKBOX Yes FORMCHECKBOX NoNumber of pregnancies FORMTEXT ????? Number of live births FORMTEXT ?????Are you pregnant or breastfeeding? FORMCHECKBOX Yes FORMCHECKBOX NoHave you had a D&C, hysterectomy, or Cesarean? FORMCHECKBOX Yes FORMCHECKBOX NoAny urinary tract, bladder, or kidney infections within the last year? FORMCHECKBOX Yes FORMCHECKBOX NoAny blood in your urine? FORMCHECKBOX Yes FORMCHECKBOX NoAny problems with control of urination? FORMCHECKBOX Yes FORMCHECKBOX NoAny hot flashes or sweating at night? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period? FORMCHECKBOX Yes FORMCHECKBOX NoExperienced any recent breast tenderness, lumps, or nipple discharge? FORMCHECKBOX Yes FORMCHECKBOX NoDate of last pap and rectal exam? FORMTEXT ?????MEN ONLYDo you usually get up to urinate during the night? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, # of times FORMTEXT ?????Do you feel pain or burning with urination? FORMCHECKBOX Yes FORMCHECKBOX NoAny blood in your urine? FORMCHECKBOX Yes FORMCHECKBOX NoDo you feel burning discharge from penis? FORMCHECKBOX Yes FORMCHECKBOX NoHas the force of your urination decreased? FORMCHECKBOX Yes FORMCHECKBOX NoHave you had any kidney, bladder, or prostate infections within the last 12 months? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have any problems emptying your bladder completely? FORMCHECKBOX Yes FORMCHECKBOX NoAny difficulty with erection or ejaculation? FORMCHECKBOX Yes FORMCHECKBOX NoAny testicle pain or swelling? FORMCHECKBOX Yes FORMCHECKBOX NoDate of last prostate and rectal exam? FORMTEXT ?????OTHER PROBLEMSCheck if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain. FORMCHECKBOX Skin FORMTEXT ????? FORMCHECKBOX Chest/Heart FORMTEXT ????? FORMCHECKBOX Recent changes in: FORMTEXT ????? FORMCHECKBOX Head/Neck FORMTEXT ????? FORMCHECKBOX Back FORMTEXT ????? FORMCHECKBOX Weight FORMTEXT ????? FORMCHECKBOX Ears FORMTEXT ????? FORMCHECKBOX Intestinal FORMTEXT ????? FORMCHECKBOX Energy level FORMTEXT ????? FORMCHECKBOX Nose FORMTEXT ????? FORMCHECKBOX Bladder FORMTEXT ????? FORMCHECKBOX Ability to sleep FORMTEXT ????? FORMCHECKBOX Throat FORMTEXT ????? FORMCHECKBOX Bowel FORMTEXT ????? FORMCHECKBOX Other pain/discomfort: FORMTEXT ????? FORMCHECKBOX Lungs FORMTEXT ????? FORMCHECKBOX Circulation FORMTEXT ????? ................
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