Primary Care Demographic and Medical History Form

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Julianna Stanley
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Primary Care Demographic and Medical History Form PATIENT DEMOGRAPHIC INFORMATION: Patient Name: Date of Birth: / / Street Address: City: State: Zip: Home Phone #: Work #: Cell #: Email: Preferred

Pets: _ Preferred Language: Religious Preference (optional): Ethnicity: Hispanic or Latino Non Hispanic or Latino Declined to Provide Unknown EMERGENCY CONTACT INFORMATION: Race: Asian Black/African

1 Primary Care Demographic and Medical History Form PATIENT DEMOGRAPHIC INFORMATION: Patient Name: Date of Birth: / / Street Address: City: State: Zip: Home Phone #: Work #: Cell #: Preferred Method of Contact: Cell Home Work Gender: Male / Female Marital Status: S M W D Occupation: Employer Name: Insurance Carrier: _ Spouse/Guardian Name: Occupation: Family Members that live with you: Pets: _ Preferred Language: Religious Preference (optional): Ethnicity: Hispanic or Latino Non Hispanic or Latino Declined to Provide Unknown EMERGENCY CONTACT INFORMATION: Race: Asian Black/African American American Indian/Alaskan Native Native Hawaiian/Pacific Islander White Other Race Declined to Provide Unknown Name: Relationship: Street Address: City: State: Zip: Home Phone #: Work #: Cell #:

2 Who can we thank for referring you to us? Primary Care Access Line Family/Friend Recommendation Hospital Employee Newspaper Radio Internet If you were referred by a current CMC patient, please let us know so we can thank them. Referral Name: Phone Number: MEDICAL HISTORY: Past Medical History: Please mark below any of the problems or conditions that you have experienced in the PAST. Abnormal Pap history Diabetes Seizures/epilepsy Alcohol or drug abuse Gallbladder disease Skin disease/skin cancer Anxiety Gout STDs Arthritis Heart Disease Stroke Asthma Hemorrhoids Thyroid disease Blood disorders ex: anemia High blood pressure Ulcers Cancer (type) High Cholesterol Urine or fecal incontinence Chronic bronchitis/copd Colitis Crohn's Disease Kidney disease Kidney stones Osteoporosis Other: please explain below CURRENT MEDICATIONS: (Including prescription, over the counter, vitamins, and supplements) Medication Name: Strength: Frequency: Reason: For additional meds please use the back of this page

3 Allergies to medications, x-ray dye, foods, or other substances: YES NO ** If yes Please list name of medications or substance and the reaction you experienced** Please provide the names and telephone numbers to your previous primary care physicians, as well as any specialists who have provided you care. Provider s Name Telephone # Reason Seen: PAST SURGICAL HISTORY Please list any past surgical history as well as any hospitalizations and the reason. Procedure/Hospitalization Date GYNECOLOGIC HISTORY Please fill in the following: if applicable Age at onset of menstrual period: Frequency: Are you regular? Current method of birth control: Are you currently menopausal? Abnormal Pap history? _ OBSTETRIC HISTORY Please complete the following: if applicable How many pregnancies have you had: Year of births: Complications (if any) FAMILY HISTORY Please complete the following family medical history to the best of your knowledge. Arthritis Diabetes: Osteoporosis Cancer: Type: Heart Disease Stroke Chemical Dependency High Blood Pressure Tuberculosis Depression/Mental Illness Kidney/Liver disease Other: Please explain:

4 Please list any of the following conditions that your blood relatives have or had and indicate the relationship to you on the next page. Relation Age Medical Conditions Cause of death (if applicable) Mother Father Brother Sister Other (Grandparents) SOCIAL HISTORY/PREVENTION: Please circle appropriate answer: Tobacco Use: Do you currently smoke or use tobacco products? YES NO Type (i.e. cigarettes, cigars, pipe, chew): Quantity/day: Did you ever smoke or use tobacco products? YES NO Type (i.e. cigarettes, cigars, pipe, chew): Years used: Do you drink alcoholic beverages? YES NO How many servings per day? per week? Do you wear your seatbelt? YES NO Do you wear a bike helmet? YES NO Do you exercise regularly? YES NO Type: Duration: Times per week: Do you have a gun in the home? YES NO Is it kept it unloaded? YES NO Locked and out of reach of children? YES NO Do you use drugs? (marijuana, cocaine etc.) YES NO

5 Have you ever engaged in activities that would put you at risk of getting AIDS? YES NO Do you wish to be tested for AIDS? YES NO Have you ever worked with hazardous materials? YES NO please explain: Are you in relationship in which you have been physically hurt? (hit, slapped, punched etc) YES NO Do you ever feel afraid of your partner? YES NO Do you have a living will? YES NO Do you have a donor card? YES NO When was your last? Mammogram: Pap smear: Breast check: Cholesterol check: Stool check for blood: Prostate exam: PSA test: _ Tetanus shot: Flu shot: Pneumonia shot: Colonosopy: Pain Management: Here at Catholic Medical Center, we recognize chronic pain is real and at times debilitating. We also realize that the medications that are used to treat chronic pain have a high potential for abuse and addiction. Our goal is to minimize the use of pain medication throughout our practices. Our policy is to establish a Pain Management Agreement in an effort to prevent the misunderstandings about medicines you may take for pain management. Additionally, we may refer you to a Pain Management Clinic as deemed appropriate by you and your provider. This information is for your physician as part of your confidential medical record. Thank you for taking the time to complete in its entirety. Signature: Date:

NOTICE TO OUR PATIENTS

NOTICE TO OUR PATIENTS SMG Chestnut Street, SMG Elm Street, SMG Mancos Valley, Southwest Walk-In Care, Southwest School-Based Health Center, SMG Market Street, SMG Orthopedics, SMG Pulmonary and Sleep Medicine, SMG General Surgery,