COMPLETE HISTORY. Updated 12/27/05
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1 COMPLETE HISTORY Updated 12/27/05 Name: Date: Date of Birth: Age: Allergies to medications: Chief reason for your visit today: How long have you had this condition? What prescription medications (if any) are you currently taking? (Please attach list if lengthy.) Are you currently taking Botanicals/Herbals? (Please attach list if lengthy.) Are you currently taking any supplements? (Vitamins, etc.)- (Please attach list if lengthy.) Are you currently using any alternative or complementary medicine? Acupuncture Guided Imagery Hypnosis Prayer Biofeedback Herbs/Supplements Meditation Please list ALL surgeries you have had (List Surgery/Date/Hospital). Have you ever had a serious illness? (List illness/date) When was your last complete physical exam? Name and location of Physician: Women: When was your last pelvic exam? Pap smear? Mammogram? Men: When was your last prostate exam (digital)? Last PSA (blood test)? When was your last eye exam? By whom? Ophthalmologist/Optometrist? When was your last dental check-up? By whom? When was your last chest x-ray? Immunizations (including date last given, if known): DPT or DT Hepatitis A Hepatitis B Measles Mumps Oral Polio Rubella TB Test & Result FAMILY HISTORY:
2 Are your parents living? M Living, Age? Father Living, Age? If deceased, from what cause? M Cause? Age? Father Cause? Age? Have any member of your family had the following? Alcoholism Arthritis Bleeding disorders Diabetes Epilepsy Heart disease High blood pressure Intestinal/colon Kidney disease Low blood sugar Mental/emotional illness Migraine Stroke Thyroid Ulcers Wt. problems Cancer (list) SOCIAL HISTORY: What do you do for fun/hobbies? art (paint/sculpt) church crafts exercise family time fish garden hunt listen music party read shopping sleep socialize sports travel How do you express your spirituality? What is your occupation? Are you happy at your current job? How much coffee do you drink daily? Tea? Sodas? How many hours of uninterrupted sleep do you get at night? Is this enough? What type of sleeping aid (if any) do you use and how often? What best describes your use of substances? Complete the table below. woodwork Substance\ Use Have you ever used? How much/how long? Do you still use? How much/how often? Cigarettes Yes No pks/day X yrs Yes No pks/day X yrs Tobacco Yes No /day X yrs Yes No /day X yrs Alcohol Yes No drinks/day or week drinks/weekend X yrs Yes No drinks/day or week drinks/weekend X yrs Pain Meds (Rx) Yes No Name/dose: Yes No Name/dose: Injection Drugs Yes No Yes No Have you ever been or are you currently addicted to prescription OR non-prescription drugs? If so, which? When was the last time you had more than five drinks in one day? Have you ever felt the need to cut back on drinking alcohol? Have you ever felt guilty about drinking? Have you ever felt you needed a drink first thing in the morning ( eye opener )? Have you ever been attacked or threatened? Witnessed violent acts/events? Have you ever been abused emotionally? Physically? Sexually? Do you feel safe in your home? If not, explain: 2.
3 Did you grow up with an alcohol/drug abuser? Someone who was incarcerated? Did you grow up primarily with a single parent? With emotional/physical neglect? Did you grow up with someone who is chronically depressed, suicidal or mentally ill? If yes to any above 10 questions, please explain. Do you talk on your cell phone while driving? Text while driving? MENTAL HEALTH HISTORY: Do you think you are under a lot of stress? (circle) now / often / always What is the major source of your stress? How do you handle stress? What do you do to relax? Have you ever had relaxation training? Are you a tense or nervous person? Do you often think of your worries/fears? Do you have any nervous habits? Have you ever suffered from phobias? Have you ever experienced a severe accident or natural disaster? Many people are troubled by frightening childhood events. Do you have this problem? Over the past 2 weeks, have you felt little interest/pleasure in activities you normally enjoy? Have you ever felt down, depressed or hopeless? Have you ever felt that life is not worth living? Have you ever felt like you wanted to kill yourself? Do you now, or have you ever, seen a psychiatrist, psychologist or counselor? If yes, for how long? Name and location of therapist: Primary reasons for therapy or diagnosis? Please list any psychiatric medication you have taken or are currently taking: Have you ever been hospitalized for a psychiatric illness? NUTRITION AND DIET Do you consider your weight to be appropriate? What is the most you have ever weighed as an adult? 3.
4 What diets or prescriptions have you tried for weight losses that have been successful? Any diets or prescriptions that have been unsuccessful? Have you ever taken laxatives to lose weight? How many meals a day do you usually eat? Induced vomiting after a meal? My diet is best defined as Regular (animal/plant) vegetarian vegan Foods frequently eaten Dairy Fish Fruit Poultr y Never Weekly More than once weekly Daily More than once daily What kind of food do you snack on? Red Meat Vegetable s Whole Grains Soy Fast food How often? EXERCISE: Do you exercise regularly (2-3 times) weekly? For how long? /min or hrs each session What types of exercise do you do regularly? aerobics cycling elliptical machine gardening hiking kayaking pilates rowing running skiing stair climber swimming team sports walking weight training yoga Do you do stretching before and after strenuous exercise? TRAVEL: Have you ever traveled outside the continental U.S.? If so, where and when? Did you ever become ill while traveling outside the U.S.? SEXUAL HEALTH: Are you in a relationship? For how long? Are you married? Are you sexually active? Do you have a partner or partners? How many? Have you ever been sexually active with a man, women or both? What is your sexual preference? (man, woman or both) At what age did you first have sexual intercourse? Have you ever had a sexually transmitted infection (STI)? If yes, list the STI type and the treatment used? 4.
5 Have you ever been diagnosed with genital herpes? When? Have you had an AIDS screening test? Date of your last AIDS test? Result? Have you ever been tested for hepatitis? When? Result? If pos? Type? Men: Do you regularly check for testicular lumps? Date of last PSA Women: Your age when you got your first period? Are your periods regular? How long is your monthly cycle? /days How long is your flow? /days Do you get PMS? Are you currently using birth control? What method(s)? Have you ever taken birth control pills? When? How long? Have you ever used IUD? When? How long? Have you ever been pregnant? How many times? Difficulty getting pregnant? Any miscarriages/abortions/stillbirths (number of each)? How many children do you currently have? Any complications with your pregnancies? Have you or your m ever taken DES (diethylstilbestrol)? Have you had any lumps or problems in your breasts? Do you check for breast lumps regularly? Date of last Mammogram: REVIEW OF SYSTEMS: Please list any problems you have had in the following areas and dates of occurrence: Skin, scalp & nails: Head/brain: Eyes, ears, nose, mouth & throat: Lungs/chest: Heart/vascular system: Stomach/intestine/colon: Back/Spine: Extremities (arms, legs, joints): Nerves/sensation: Hormones/glands: Bladder/kidneys/genitalia: 5.
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