HOME - Community Health Alliance



ADULT HEALTH HISTORY Patient Name:DOB:Date:Main reason for today’s visit:Where were you getting your MEDICAL care before? (Previous doctor/PCP):Where were you getting your DENTAL care before? (Dentist):In the past 2 weeks, have you been bothered by: Little interest or pleasure in doing things? Yes No Feeling down, depressed or hopeless? Yes No Review of symptoms: Please mark the box (?) and/or circle any persistent symptoms you have had in the past few months. Read through every section and check “no problems” if none of the symptoms apply to you. List other concerns above.GeneralRespiratoryGastrointestinalPsychiatric__ Unexplained weight loss/gain__ Unexplained fatigue/weakness__ Fall asleep during day when sitting __ Fever, chills__ No problems__ Altered breathing during sleep__ Cough producing blood__ Cough/wheeze__ Loud snoring__ short of breath with exertion__ No problems __Heartburn/reflux/indigestion__ Blood or change in bowel movement__ Constipation__ No problems__ Anxiety/stress__ Sleep problems__ Lack of concentration__ No problemsSkinHematologic/LymphaticEyesAllergy/Immune__ New or change in a mole__ Rash/itching__ No problems__ Swollen glands__ Easy bruising__No problems__ Change in Vision__ Eye pain/redness__ No problems__ Hay fever/allergies__ Frequent infections__ Lowered immune system__ No problemsNeurologicalGenitourinaryEars/Nose/ThroatWomen only__ Headache__ Memory loss__ Fainting/dizziness__ Numbness/tingling__ Unsteady gait__ Frequent falls__ No problems__ Leaking urine__ Blood in urine__ Nighttime urination or increase frequency__ Discharge; penis or vagina__ Concern with sexual function__ No problems__ Nosebleed__ Trouble swallowing__ Frequent sore throat__ Hoarseness__ Hearing loss__ Ringing in ears__ No problems__ Pre-menstrual symptoms (bloating, cramps, irritability)__ Problem with menstrual periods__ Hot flashes__ Night sweats__ No problemsCardiovascularMusculoskeletalEndocrineBreast__ Chest pain/discomfort__ Palpitations(fast or irregular heart beat)__ No problems__ Neck pain__ Back pain__ Muscle/joint pain__ No problems__ Heat or cold sensitivity__ No problems__ Breast lump/pain__ Nipple discharge__ No problemsPlease list (or show us your own printed record) all prescription and non-prescription medications, vitamins, home remedies, birth control pill, herbs, inhalers, etc. TAKE NO MEDICATIONS History of Blood thinning medications Current/Past Chemo Therapy History of steroid therapy History of aspirin therapy History of Osteoporosis medication MEDICATIONSDOSE(e.g. mg/pill)HOW MANY TIMES PER DAY?MEDICATIONSDOSE(e.g. mg/pill)HOW MANY TIMES PER DAY?ALLEGIES OR INTOLERANCE TO MEDICATIONS:Are you allergic to the following? DK (Don’t know) None Latex Yes No DK Metals Yes No DK Local anesthetic Yes No DK Iodine Yes No DK Ibuprofen Yes No DK Sulfa/Sulfite Yes No DK Codeine Yes No DK Aspirin Yes No DKPenicillin Yes No DK Other ANTIBIOTICS Yes No DK Other _____________________ PERSONAL MEDICAL HISTORY: Do you have now (current) or have had (past) any of the following conditions?CONDITIONCURRENTPASTCONDITIONCURRENTPASTAlcohol/Drug abuseHeart DiseaseAnxietyHeart Valve ReplacementArthritisHigh Blood PressureAsthma/COPD/Lung DiseaseHigh CholesterolBleeding disorderHIV/AIDSCancer breastJoint replacement/ whenCancer ColonKidney Disease/Failure (chronic) Cancer CervicalLiver Disease/Cirrhosis/HepatitisCancer other type (See below)Osteoporosis (See below)Congenital MethemoglobinemiaRadiation TherapyDepressionRheumatic FeverDiabetesSeizure/EpilepsyDo you have active/latent Tuberculosis/TBSleep ApneaGastroesophageal Reflux (heartburn/GERD)StrokeGlaucomaThyroid DiseaseGynecological conditions (other)If you have Osteoporosis: Are you taking or scheduled to begin taking either of the following medications, Alendronate (Fosamax) or Risedronate (Actonel) for osteoporosis? □ Yes □ NoIf you have/had cancer:Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous Bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, Multiple Myeloma or Metastatic Cancer □ Yes □ NoFAMILY HISTORY-Indicate which relative has had the following disease (parents and siblings are most important)Are you adopted and have no known family history? Yes NoDiseaseMotherFatherSiblingsDiseaseMotherFatherSiblingsDiseaseMotherFatherSiblingsNo significant history knownCancer Ovarian/ CervicalHigh Blood Pressure/ HypertensionAlcohol abuse/Drug abuseCancer ProstateHigh CholesterolAlzheimer’s/DementiaCancer other typeHypothyroidism/Thyroid DiseaseAutoimmune DiseaseDepression/Suicide/ AnxietyKidney DiseaseCancer BreastDiabetesOsteoporosisCancer ColonHeart DiseaseStroke/CVAOTHER HEALTH ISSUESTobacco Use: Yes No Never Quit date_________ Approximately how many packs/day?____ # of years:_______ Pipe Cigar Snuff Chew Electronic Cigarettes Cigarettes Alcohol Use:Do you drink alcohol? Yes No # of drinks/week______ Is your alcohol use a concern for you or others? Yes NoWomen’s Health History:Total number of pregnancies:____ Number of deliveries: _____Age periods started:___________ Age periods ended: _________Are you pregnant? yes no Due date: ___________Drug Use:Do you use recreational drugs? Yes NoHave you ever used needles to inject drugs? Yes NoSexual Activity: Decline to answerSexual active: Yes No Not currentlySexual Partner(s) is/are/have been: Male FemaleBirth control method: _________________ None neededHistory of sexually transmitted disease Yes NoSafety: Decline to answerDo you use a bike helmet? Yes NoDo you use seatbelts consistently? Yes NoDoes your home have a working smoke detector? Yes NoIf you have guns in your home, are they locked up? Yes No Is violence at home a concern for you? Yes NoSocial Support:Spouse/Partner’s name: ________________________________ Number of children ________ Who lives with you? Ages if under 18 years of age:Have you completed an Advance Directive for Health Care Living Will or POLST (Physician Orders for Life Sustaining Therapy?) Yes No If yes, was copy provided? Yes NoEducation Level:Highest grade completed:DENTAL HISTORYAre your teeth sensitive to the cold, hot, sweets or pressure? Yes No DKDo you have any clicking, popping or discomfort in the jaw? Yes No DKAre you experiencing dental pain or discomfort? Yes No DKDo you brux (clench) or grind your teeth? Yes No DKDo you have any oral piercings/jewelry? Yes No DKOral habits (chewing finger nails, clenching, etc.) Yes No DKIs your mouth dry? Yes No DKDo you have any sores or ulcers in your mouth? Yes No DKHave you had any periodontal (gum) treatments? Yes No DKHave you ever had orthodontic (braces) treatment? Yes No DKDo you bleach your teeth? Yes No DKDo you wear a mouth guard when playing contact sports? Yes No DKHave you had any problems associated with previous dental treatment Yes No DKHave you ever had a serious injury to your head or mouth? Yes No DKHow many times do you brush daily? How many times do you floss daily?How do you feel about your smile? Do you drink bottled water or filtered water? Yes No DKIf yes, how often? Circle one: Daily Weekly OccasionallyDate of your last dental exam:________________________ UnknownWhat was done at the time:_________________________ Unknown Date of last X-rays:____________ UnknownHas a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? Yes No DKName of physician or dentist making recommendation: Unknown_____________________________________________ __________________________________ Signature Date ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download