Strong Internal Medicine - Welcome to URMC - Rochester, NY



Strong Internal MedicineHealth History Questionnaire(please print clearly)Patient Information:Name: ___________________________________________________Date of Birth: ____________ Marital Status: Single Married Divorced/ Separated PartneredMedical Information:Do you have any major health concerns or questions that you would like to discuss with the health care provider? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Past Medical History: (Check all items that apply to you and fill in the blanks as needed)__allergies__anemia or blood problems__arthritis__asthma__blood transfusion, year__________cancer/tumor, type_____________chickenpox, year___________COPD/emphysema__diabetes__drug or alcohol abuse__epilepsy or seizure__hearing loss__heart disease or heart attack__hepatitis__HIV/AIDS__high blood pressure__kidney disease or stones__ulcer disease or reflux__depression/anxiety__other mental illness__sexually-transmitted disease__skin disease, eczema, psoriasis__stroke__thyroid disease__other, specify_____________________________________________ _____________________________Past Surgical History: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Medications: (List all medications with dosages, include over-the-counter medications and herbs)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Allergies: No known drug allergiesAllergic toDrug:_________________________________Reaction: ________________________Drug:_________________________________Reaction: ________________________ No known food or environmental allergies (peanuts, bees, pollen, etc) Allergic toFood/Other: ___________________________Reaction: ________________________Food/Other: ___________________________Reaction: ________________________Preventive Services: (Please list the date that you last had these tests or procedures.)Physical: Never or Date: _____________Lipid/cholesterol panel: Never or Date: _____________ Colonoscopy: Never or Date: _____________Bone density or DEXA scan: Never or Date: _____________ImmunizationsTetanusDate ___________ Influenza (Flu) Date ___________Hepatitis BDate ___________ PneumoniaDate ___________Chicken PoxDate ___________ Gardasil (HPV)Date ___________Zoster (shingles)Date ___________ If you do not know your immunization history, please indicate the doctor or office that may have immunization records: Name: _____________________________________________________________Address: ___________________________________________________________Phone Number: ______________________________________________________Women Only: Date of last Pap smear:_______________ Date of last mammogram:_________________Risk Assessment/Social History:Do you currently smoke? No Yes If yes, how many packs per day ____ for how many years _____Did you smoke in the past? No Yes If yes, when did you quit? __________________Have you had exposure to smoke now or in the past? No Yes How long: _________________How many alcoholic drinks do you have in a typical day? __________________Have you used illegal or recreational drugs in the past year? No Yes Has anyone complained about your drug or ETOH use? No Yes How many caffeinated beverages do you have per day? ___________________Are you on a special diet (vegetarian, gluten free, etc)? No Yes If yes, specify: _________________How many hours of sleep do you get on a typical night? _________Do you exercise regularly? No Yes (specify how often) _____________________________Do you wear helmets for sports (biking, skiing, etc)? __No __Yes __ N/ADo you use a seatbelt? No Yes Do you use contraception if you are sexually active? No Yes N/ADo you practice safe sex if you are sexually active? No Yes N/AHave you ever been a victim of abuse? No Yes When: _____________________________________Have you been exposed to hazardous material? No Yes If yes, specify: ______________________Do you have smoke detectors in your home? No Yes Do you have carbon monoxide detectors in your home? No Yes Have you often been bothered by feeling down, depressed, or hopeless? No Yes Have you often been bothered by little interest or pleasure in doing things? No Yes Do you have a health care proxy or advanced directive? No Yes With whom do you live? ____________________________________________________________Are you …. ? ___ employed; type of employment _________________________ homemaker___ retired___ full-time student: field of study _________________________ disabled: reason / year ________________________________ other; specify _____________________________________Family History:MotherFatherGrandparentBrother/SisterChildAlzheimersAsthmaArthritisAllergiesAlcoholismBlood disordersCancer (specify type)Depression/anxietyOther mental illnessDiabetesHeart diseaseHigh blood pressureStomach/intestinal diseaseStrokeSkin diseaseThyroid problem Current Age(s)or Age at deathOther Health Care Providers: Do you have a…?Name and addressDentist No Yes ____________________________________________Eye doctor No Yes ____________________________________________Mental health No Yes ____________________________________________OB-GYN No Yes ____________________________________________Other _________________________________________________________Review of Systems:(check any of the following that you have or have had in the past 6 months)SkinNeurologicRashesSeizuresChange in a wart or moleParalysisEar nose and throatNumbness or tinglingNosebleedsDizzinessAllergiesBalance problemsSinus problemsDigestionEye painHeartburn or refluxTrouble seeingUlcerGlaucomaNausea/vomitingDouble visionDiarrheaEar painConstipationTrouble hearingAbdominal painHoarsenessBlack or bloody stoolFrequent sore throatsLiver or gallbladder troubleRespiratoryJaundice or yellow skinShortness of breathUrinaryWheezingPain on urinationCoughFrequent urinationCoughing bloodFrequent urination at nightCardiovascularInability to hold urineHeart attackBlood and urineChest painKidney stonesMurmurMental/emotionalIrregular heartbeat/ palpitationsAnxietySwelling in anklesDepressionEndocrinePoor concentrationHeat intolerancePoor memoryCold intoleranceGeneralExcessive thirstPoor sleep/insomniaExcessive urinationFatigue/low energyHair lossFever/chillsChange in weightPoor appetiteMuscles/joints/bonesWomen onlyJoint painChange in periodsMuscle painVaginal itching or dischargeOsteoporosisBreast lumpsJoint swellingBleeding after menopauseMen onlyTesticular swellingChange in urinary stream ................
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