Family Centered Healthcare, P.A.



Health History Questionnaire:Name_____________________________________________________Date of birth___________ Address Local phone number Preferred Pharmacy Please describe what problem or concern brought you to our office today:Primarily to establish careAlternative phone number Pharmacy phone number ? Other (please briefly describe) ______________________________________ Special Communication Needs:Language preference:If 'yes' to any of the questions below, how can we assist?Visual impairmentYesNoCognitive impairmentYesNoHearing impairmentYesNoSensory impairmentYesNoSpeech impairmentYesNoOther:Personal Health HistoryPrevious Surgical ProceduresPlease check past or current problems or conditionsPlease check if you have had any of the followingConditionConditionProcedureYearHypertensionSeizuresHeart surgeryHigh cholesterolHeadachesCarotid artery surgeryDiabetesStrokeVascular surgery / stentHeart attack or anginaProstate problemAbdominal aneurysm repairIrregular heart rhythmBreast problemHysterectomyCongestive heart failureUrinary tract infectionsGallbladder removedAsthmaOsteoarthritisAppendix removedEmphysema or chronic bronchitisCancer (Please list type)TonsillectomyPneumoniaThyroid problemJoint replacementGastroesophageal reflux diseaseBleeding disorderBreast cancer surgeryStomach ulcerAddiction IssuesProstate cancer surgeryKidney problemsDepression or anxietyHerniaLiver disease/hepatitisMental IllnessPacemakerColon cancerOther (please describe)Other (please describe)Bowel/digestive problemSocial History:Please circle appropriate answers below and provide explanations where appropriateMarital status:? Single? Married? Divorced? Widowed? Life PartnerEducation level: ? Did not Graduate? High School? Some College ? Bachelor’s Degree? Master’s Degree or HigherOccupation:Occupational concerns:? Stress? Hazardous substances? Heavy liftingHow stressful would you rate your current living situation: (Circle number)No stress 0 1 2 3 4 5 6 7 8 9 10 Very StressfulAre there financial concerns that affect your ability to seek healthcare?? No? YesIf yes, describe belowAre there any religious or cultural factors that you would like us to take into account when planning your healthcare?Current Health ConcernsPlease check problems or conditions that you are CURRENTLY experiencingChest painRectal bleedingEye painNervousnessShortness of breathBlack/tarry stoolsLoss of visionPain in testiclesWheezingWeight lossDouble visionLoss of libidoCoughWeight gainMemory lossImpotenceCoughing up bloodLoss of appetiteRinging in earsBreast painSore throatDifficulty swallowingPain in earsBreast dischargeNasal congestionDiarrheaNose bleedsOther (please describe below)Irregular heartbeatConstipationHoarsenessFast heartbeatPainful urinationEasy bleedingHigh blood pressureBlood in urineEasy bruisingLow blood pressureUrine frequencyRashLightheadednessDecrease in urine flowChanges in moleFemales - Please completeDizziness/faintingUrine leakageSore that won’t healMenstrual flow:Reg.? Irreg. ? Pain/crampsAbdominal painHeadacheFatigue/lethargyHeartburnWeaknessInsomniaDays of flow __ Length of cycle IndigestionLoss of strengthForgetfulness1st day of last period Ankle swellingBalance problemsDepressionPain or bleeding after sexNauseaPain, weakness, or numbness inNumber of pregnancies ___VomitingArms? Hips? BackMiscarriages Vomiting bloodLegs? NeckShouldersBirth control method Change in bowel habitsHands? FeetKneesFamily HistoryRelationshipLiving Y/NAgeMajor Medical Problems and/or Cause of DeathFatherMotherSiblingsChildrenSpecifically have any of your relatives had the following conditionsConditionRelativeConditionRelativeMental illnessChemical dependencyAllergies?Please list any allergies to medications or foodsMedications:Please list any medications that you take including over the counter medications, herbs, and supplements.Include dose and frequencyHealth Maintenance:Please check whether you have had the following preventive services and enter the year of the serviceImmunizationsYearTestsYearTetanus vaccine / TdapYesNoPap smear/pelvicYesNoPneumonia vaccineYesNoMammogramYesNoInfluenza vaccineYesNoBone dexaYesNoShingles vaccineYesNoColonoscopyYesNoProstate testYesNoSpecialty Providers:In order that we can best coordinate your care, please list any medical providers you see outside of this practice and list the year that you last saw themEye doctorNephrologistCardiologistPsychiatristOncologistAllergistUrologist / GynecologistVascularGastroenterologistPulmonologistEndocrinologistOtherHealth Behaviors:Tobacco use:? Never? Quit (when)? Current smokerIf current smoker how many packs per day for how many years___________Alcohol intake:? No? YesIf yes how many drinks/how oftenIllicit drug use (including marijuana, cocaine, steroids):? Never? Past? CurrentIf past or current drug use describe:Exposure to secondhand smoke? Yes? NoWear a seatbeltYesNoEat a diet high in fruits and vegetables? Yes? NoSee a dentist at least once a yearYesNoGet 30 minutes of exercise 5 times a week? Yes? NoWear sunscreenYesNoAdvance Care Planning:Do currently have, or would you like information on, any of the following itemsLiving Will:HaveDon’t HaveWant InformationDurable Power of Attorney:HaveDon’t HaveWant InformationDNR Order:HaveDon’t HaveWant InformationPatient Signature:Date: ................
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