PAST MEDICAL HISTORY: []Rheumatic Fever []Scarlet Fever ...
Name ____________________________________ DOB: ______________Date: ________________
How did you hear about our practice:_________________________________________________
YOUR MEDICAL HISTORY:
Asthma (Yes (No Heart disease/ heart attack (Yes (No Blood clots (Yes (No
High Blood Pressure (Yes (No Cancer_______________ (Yes (No Seizures (Yes (No
Diabetes (Yes (No High/Bad Cholesterol (Yes (No Enlarged prostate (Yes (No
Emphysema/COPD (Yes (No Stroke (Yes (No HIV/ AIDS (Yes (No
Autoimmune disease (Yes (No Anxiety (Yes (No Glaucoma (Yes (No
Heartburn/ reflux (Yes (No history of alcohol or drug abuse (Yes (No COVID 19 (Yes (No
Thyroid disease (Yes (No depression (Yes (No
(Other __________________________________________________________________________
SURGERIES: (No surgeries (gall bladder removed ( Partial hysterectomy ( total hysterectomy __________________________
____________________________________________________________________________________________________________
Medications:______________________________________________________________________________
(Use back of page if needed)
Preferred pharmacy:_______________________________________Allergies:______________________
FAMILY HISTORY (list which relative):
Please list who has or had the follow conditions: (mother, father, brother, sister, paternal or maternal grandparents, etc.)
(High Blood Pressure _____________ (Diabetes____________________________
(High Cholesterol ______________ (Cancer (Type) ________________________ age __________
(Coronary Artery Disease___________ (before age 50 (Heart Attack____________________(before age 50
(Sudden Death_______________________ (Heart Failure____________
(Stroke__________________________(Seizures_______________ (Mental illness______________________________
( other__________________________________________________________________________________________________
(None of the Above
Mother (alive (deceased ____age (unknown Father (alive (deceased ____age (unknown Maternal Grandmother (alive (deceased ____age (unknown Maternal Grandfather (alive (deceased ____age (unknown Paternal Grandmother (alive (deceased ____age (unknown Paternal Grandfather (alive (deceased ____age (unknown
Brothers: how many?_______________________________________________Deceased:_____________________
Sisters: how many?_________________________________________________Deceased:_____________________
SOCIAL HISTORY:
Do you wear your seat belt? (Yes (No (Sometimes Do you exercise? (Yes (No If so, how often________________
Do you feel safe in your home/ relationship? (Yes (No Have you ever been made to have sex against your will? (Yes (No
Have you ever had sex? (Yes (No Have you had sex in the last 12 months? (No (Yes
Do you have sex with men? (Yes (No Do you have sex with women? (Yes (No ( I do not have sex (Other_________
Number of sexual partners in last 12months________
(Married (Single (Divorced (Widowed (Separated ( Partnership (Other______________
What birth control do you use? (none (pills (my partner takes care of this (condoms(vasectomy (_______________
Occupation:_______________________________________________________________________
Do you do any of the following:
Smoke/ tobacco? (No (Yes ( former smoker If so, how many packs per day (now or in past)? ___________
Drink Coffee/Soft drinks/Tea: (No (Yes If so, how many cups per day? ___________
Drink Alcohol: (No (Yes if so, how much/how often? _________________ Have you ever felt you should cut down on your drinking? __Yes __No Have people annoyed you by criticizing your drinking? __Yes __No Have you ever felt bad or guilty about your drinking? __Yes __No Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? __Yes __No Do you vape?(No (Yes
Use street drugs: (No (Yes ( Yes, but in the past. If so, what drug(s)? ____________________________
Name ___________________________________________DOB: ______________
How can we help you today? (Physical Any concerns? (No (Yes(please list)___________________________________________
REVIEW OF SYSTEMS: Check all that apply if happened within the last 6 months
Do you experience any of the following:
1. General:(Chills (Fever (Fatigue/Tired (Recent Weight Loss (Weight Gain (None
2. EENT: ( Hearing loss (Vision changes (Changes in taste (Changes in smell
(Sinus problems (Ringing in ears (Loud Snoring (None ( Other_______________
3. Cardiovascular: (Chest pain (Heart racing/ palpitations (Swelling in legs (None ( Other________
4. Respiratory: (Cough (Sputum (Wheezing (Trouble breathing (None ( Other_______________
5. Gastrointestinal: (Abdominal pain ( (Nausea/Vomiting (Painful or trouble swallowing (Blood in stool (Change in stool (Diarrhea (Constipation (None ( Other_______________
6. Genitourinary: (Discharge (Blood in urine (Urine leakage/incontinence (Bladder frequency/ Urgency (Trouble with sex (Straining to urinate (Getting up at night to urinate (None
(Changes to breast
(female) (Abnormal Periods (Abnormal Vaginal Bleeding (Vaginal itching or Burning (None
(male) (Erectile Dysfunction ( Other______________________ (None
7. Musculoskeletal: ( Muscle weakness (Arthritis (joint swelling (Painful Muscles (Painful Joints (None Have you fallen down in the last year? (Yes ( No ( Other____________________
8. Hematologic: (Easy Bleeding (Nosebleeds (Painful or Swollen Lymph Nodes (Night sweats (None ( Other_________________
9. Neurologic: (Seizures (Balance Problems (Chronic Headaches (Numbness/ tingling (Seizures (Trouble concentrating (Memory trouble (None ( Other_______________
10. Endocrine: ( Abnormal thirst (Excessive urination (Heat or cold intolerance (None ( Other______
11. Dermatologic/skin:(Sores that do not heal (Rash (Eczema (Lump (None ( Other____________
12. Mood: (Anxiety (Depression (Trouble controlling stress/worry (Hallucinations (Sleep difficulty/ insomnia (None ( Other_______________
13. Last mammogram__________________Last pap smear_______________________ Last bone density_______________
14. Last prostate check_________________Last colon cancer screening__________________________
|Over the last 2 weeks how often have you been bothered by|Not at all |A few days a week |More than ½ the week |Almost everyday |
|any of the following | | | | |
|Little interest or pleasure in doing things |0 |1 |2 |3 |
|Feeling down, depressed, or hopeless |0 |1 |2 |3 |
15. Would you like to be tested for (Diabetes (High cholesterol (Sexually Transmitted Infections
16. Do you want a flu shot (Sept-Feb)? (Yes (No last vaccine ______Tetanus Vaccine? (Yes (No last vaccine ________
Pneumonia vaccine (Only if age>50, smoker, kidney, lung or heart disease, asthma) (Yes (No last vaccine__________________
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