SOCIAL HISTORY:
HEALTH HISTORY
Patient Name ________________________________________________ DOB ____________________
LIST ALL ALLERGIES (to medications, food or latex)
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING
(Over the counter drugs, non-prescription drugs and herbal supplements should be included)
|Medication Name |Dosage |Frequency |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
LIST ANY HOSPITALIZATIONS AND/OR SURGERIES YOU HAVE HAD (with dates)
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
FAMILY MEDICAL HISTORY
| |
|Last Flu shot _____________________________ |
|Last Pneumonia vaccine _____________________ |
|Last Tetanus booster _____________________ |
|Last TB skin test ____________________ |
|Last Cholesterol level ______________________ |
SOCIAL HISTORY
Do you smoke? ? YES ? NO How many packs per day? _____________ For how many years? ____________
Drink alcoholic beverages? ? YES ? NO Average number per week? ____________
Do you take any street drugs? ? YES ? NO What type? _________________________________
How many caffeinated beverages daily? _______________________ What type? ___________________________________
Do you exercise? ? YES ? NO How frequently? ___________ What type? ___________________________________
Any difficulty with sleep? ? YES ? NO Describe: ______________________________________________________
MEDICAL PROBLEMS YOU HAVE NOW OR HAVE HAD IN PAST
(You may write in anything not specifically listed)
NOW PAST
? ? AIDS / HIV
? ? Allergies / Hay fever
? ? Anemia
? ? Asthma / Wheezing
? ? Arthritis / Rheumatism
? ? Bladder Problems (painful, frequency, loss of control, blood in urine)
? ? Bleeding problems / Bruising
? ? Bronchitis / Chronic Cough
? ? Cancer
? ? Change in Bowel Habits / Constipation / Diarrhea / Blood or Tarry Stools
? ? Chest Pain
? ? Childhood Illness (specify): ___________________________________________________________
? ? Convulsions / Seizures
? ? Depression / Mood Disorders / Mental Illness
? ? Diabetes
? ? Diverticulitis / Crohn’s Disease
? ? Dizziness / Fainting
? ? Ear Problems
? ? Eye Problems / Glaucoma
? ? Foot Problems (pain, numb, or cold feet)
? ? Gall Bladder Disease
? ? Gout
? ? Headaches (frequent or Migraine)
? ? Heart Problems (Murmurs / Mitral Valve) _______________________________________________
? ? Heart Attack / Congestive Heart Failure
? ? Hemorrhoids
? ? Hepatitis / Yellow Jaundice
? ? Hernia
? ? High Blood Pressure
? ? Indigestion / Frequent Heartburn / Hiatal Hernia
? ? Kidney Problems (stones or frequent infections)
? ? Leg problems (pain or difficulty walking, varicose veins)
? ? Lung Problems / COPD / Emphysema
? ? Nose Bleeds
? ? Osteoporosis
? ? Pneumonia
? ? Prostate Disease
? ? Sinus Problems
? ? Skin Disorders – Acne / Psoriasis / Eczema / Rashes
? ? Stomach Ulcer
? ? Stroke / TIA
? ? Thyroid Disease
? ? Weight (recent unexplained loss or gain)
Other illnesses or additional details
________________________________________________________________________________________________________________________________
FEMALE PATIENTS ONLY
Are you pregnant? ? YES ? NO
Number of pregnancies: _______ Miscarriages: _______ Abortions: _______ Live Births: ________
Date of last menstrual cycle: __________ Usual length of cycle: __________ Days of flow: __________
Usual menstrual cycle: ? Regular ? Irregular ? Painful/Cramps
Birth Control Method: _____________________________________________________________________
If menopausal, do you experience any symptoms? ? YES ? NO
Date of last PAP test: ______________________________________________ ? Normal ? Abnormal
Date and Facility of last Mammogram: ________________________________ ? Normal ? Abnormal
How often do you perform Self Breast Exams? _________________________________________________
MALE PATIENTS ONLY
Any urinary complaints? (hesitation in starting urine stream, decrease in force or flow, dribbling)
How many times per night do you awaken to urinate? ___________________________________________
Any difficulty in getting or maintaining an erection? ? YES ? NO
Date of last prostate exam: _________________________________________________________________
Have you had a PSA blood test? ? YES ? NO
Date of PSA: ____________________________________________________ ? Normal ? Abnormal
................
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