Meadows Wellness Clinic - "Healthcare At Its Finest"
151 Mary Esther Blvd, STE 403 A, Mary Esther, FL, 32569Phone: (850) 226-8117Fax: (850) 226-8117PRINT NAME: ________________________________DOB:__________________DATE:______________Mailing Address ________________________ City ___________________State ________ Zip ____________Home Phone __________________ Cell Phone _________________Work Phone_____________Age _______ Email address: _______________________________________NEW PATIENT PAST MEDICAL HISTORYPlease list any major accidents/surgeries and/or hospitalizations (with the year and resulting diagnosis):Are you currently seeing any specialists? If so, list the specialist’s name(s) and phone number(s) below:Are you currently or have you previously been a patient at Behavioral Health? Yes/NoFAMILY HISTORY:Father: Living/Deceased/Current Age/DOB or Age at Death:___________Cause of death or health conditions?Mother: Living/Deceased/Current Age/DOB or Age at Death:___________Cause of death or health conditions?Brother(s) #___Any Deaths before age 50/Cause?Any health conditionsSister(s) #___Any Deaths before age 50/Cause?Any health conditionsDo you have Children (#Boys/Girls)___/___Any Deaths before age 1/Cause?_________Any health conditions?Please tell us the month/year of your most recent:Blood tests _____/______Bone Density Scan_____/_____Colonoscopy_____/_____X-rays _____/______What were the x-rays for?CT/MRI_____/_____What was the CT/MRI for?FEMALES ONLY:How many times have you been pregnant?Any miscarriages/abortions?How many children were born living?Are you sexually active?If so, what form of birth control/STD prevention are you using?Have you had any surgery that prevents you from getting pregnant?Have you gone through menopause?151 Mary Esther Blvd, STE 403 A, Mary Esther, FL, 32569Phone: (850) 226-8117Fax: (850) 226-8117PRINT NAME: ________________________________DOB:__________________DATE:______________Please tell us the month/year of your most recent:Well woman exam/Pap smear_____/_____Mammogram_____/_____Have there been any abnormalities on your Pap smears or mammograms that you are aware of?MALES ONLY:Are you sexually active?If so, what form of birth control/STD prevention are you using?Have you had a vasectomy?Please tell us the month/year of your most recent Testicular/prostate exam or PSA blood test:LIFESTYLE HISTORY:Gender identity (male, female)Sexual relations (men, women, both)Do you currently smoke? Yes/NoIf no, did you ever smoke? Yes/NoIf yes, at what age did you started smoking?Type of product:Cigarettes/Cigars/Pipe/Hookah/Smokeless Tobacco (Dip)How much do you smoke per day and for how long?Do you drink alcohol? Yes/NoIf no, did you ever drink? Yes/NoIf yes, at what age did you started drinking?If yes, type of product (Beer/Wine/Liquor)?How much do you drink per day and for how long?Do you have a history of alcohol abuse/alcoholism that required admission to a program or jail? Yes/NoDo you use any street or illicit drugs? Yes/No If no, did you ever use drugs? Yes/NoIf yes, at what age did you started drinking?If yes, type of product (Pills/Powders/Gas/Smoke/IV drugs)?How much do you use per day?Do you have a controlled substance abuse history that required admission to a program or jail?Yes/NoDo you have tattoos? Yes/NoIf yes, were they done at a licensed facility?Yes/NoHave you ever been screened for Hepatitis C?Yes/NoHave you ever been a victim of abuse as a child or an adult?Yes/No__________________________If yes, have you received any counseling?Yes/No__________________________Do you need a referral for counseling?Yes/NoBriefly describe your home environment: Are you safe? Do you have family/friends nearby or available?What is your marital status (Single/Married/Divorced/Widowed)?151 Mary Esther Blvd, STE 403 A, Mary Esther, FL, 32569Phone: (850) 226-8117Fax: (850) 226-8117PRINT NAME: ________________________________DOB:__________________DATE:______________Briefly describe your diet and any dietary restrictions you may have:Do you need a referral for counseling?Yes/NoBriefly describe your home environment: Are you safe? Do you have family/friends nearby or available?What is your marital status (Single/Married/Divorced/Widowed)?Briefly describe your diet and any dietary restrictions you may have:What is your highest level of education (Below High School/High School/Vocational-Trade/College)?Are you currently employed? Yes/NoIf no, are you:Unemployed/Retired/Disabled?If yes, briefly describe what you do for a living:______________________________________________In your own words what is the main reason you are here today?BODY SYSTEMS (ROS): Indicate by circling the symptoms you have-feel free to comment: Do you have fever/chills/weakness/fatigue/unintended weight loss/unintended weight gain?Do you have recurrent issues with fainting/tremors/extremity weakness/extremity tingling, numbness or loss of sensation?Do you have ongoing issues with anxiety/depression/insomnia/thoughts of harming yourself or others? Do you hear or see things others do not? Do you believe you are in danger?Do you have recurring pain in the head or dizziness? Are you concerned with your hair falling out in clumps or growing in places it shouldn’t?Do you have excessive thirst, hunger or urination? Do you have difficulty with extremes in temperature-too hot or too cold? Do you have any recurring problems with eye pain/blurry vision/double vision/loss of vision/dryness?Do you have any recurring problems with ear pain/discharge/infections/wax buildup?Do you have any recurring problems with nose bleeding or discharge, nasal congestion, or runny nose?151 Mary Esther Blvd, STE 403 A, Mary Esther, FL, 32569Phone: (850) 226-8117Fax: (850) 226-8117PRINT NAME: ________________________________DOB:__________________DATE:______________Do you have recurring issues with pain in your throat/difficulty swallowing/choking on food or liquids?Do you have any pain or bleeding in your mouth, teeth or gums?Do you have any pain/swelling/restriction of movement in your neck? Have you been diagnosed with a thyroid problem or had surgery or treatment for hyperthyroidism (overactive thyroid)?Do you have any recurring coughing/wheezing/trouble breathing? Do you wake up short of breath? Do you need to sleep in a chair or propped with two or more pillows? Have you ever been diagnosed with asthma/emphysema/COPD?Do you have recurring chest pain/pressure/tightness? Do you have swelling in your hands or feet? Have you been diagnosed with an irregular heartbeat/heart murmur/other heart condition? Have you ever had a heart attack?Do you have recurring issues with breast pain/lumps/nipple discharge? Have you ever had breast surgery or a biopsy? Do you perform monthly breast self-examinations?Do you have recurring problems with your stomach or bowels such as heartburn/pain/gas/ulcers nausea/vomiting/diarrhea/constipation? Do you have a feeding tube or colostomy?Do you have recurring problems with urination such as pain/going too often/not emptying completely/sudden urge to go badly? Do you have any recurring issues with sexual activity such as pain/inability to perform/lack of desire?Do you have recurring issues with your neck/back/spine/ribcage? Have you ever broken a bone?Do you have any recurring problems with your muscles, bones or joints such as pain/weakness/numbness/inability to move a body part? Do you need assistance with moving around such as a cane/walker/wheelchair?Have you noticed any concerning changes in your skin or nails such as discoloration/rashes/wounds that won’t heal/unusual bruises? Location on body?___________________Have you ever been diagnosed with skin cancer?Do you have any other concerns about anything not listed above??2018 by Meadows Wellness Clinic ................
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