Patient s name Patient s phone numbers Emergency contact name Emergency contact phone number Relationship to patient
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1 Advocate Condell Wound Healing Center 801 South Milwaukee Ave, West Tower Libertyville, IL Patient s name Patient s phone numbers Emergency contact name Emergency contact phone number Relationship to patient Primary physician Referring physician Home health care agency Phone number Home health nurse Pharmacy name, location, and phone number Allergies Medications (Please list name, dose, and frequency for each and include over the counter medications you are taking. If you have a list, we will be happy to make a copy for you.) Page 1 of 6
2 Medical history Cardiovascular Arrhythmia Heart failure (CHF) High blood pressure Low blood pressure Heart attack Blood clots Leg swelling (edema) Peripheral vascular disease Leg cramps High cholesterol Endocrine Diabetes Hypothyroid Hyperthyroid Immunologic Long term steroid use Lupus Rheumatoid arthritis Scleroderma Gastrointestinal Cirrhosis Hepatitis Jaundice Swallowing problems Change in appetite Recent weight gain or loss Bowel incontinence Diarrhea Blood in stools Ulcer Musculoskeletal Fibromyalgia Fractures Osteoarthritis Gout Charcot foot Amputation Page 2 of 6
3 Neurologic Respiratory Stroke Asthma TIA Bronchitis Seizures COPD Spinal cord injury Emphysema Muscular dystrophy Short of breath at rest Migraines Short of breath on exertion Dizziness Pneumothorax Syncope Tuberculosis Wheezing Psychological Depression Anxiety Alcoholism Chemical dependency Suicide attempt Abuse Genitourinary Kidney disease Dialysis Kidney stones Blood in urine Urinary incontinence Prostate problems Hematological Anemia Bleeding disorder Cancer Surgical history Page 3 of 6
4 Pain Are you currently in pain? Yes/No Have you recently been in pain? Yes/No Location of pain Quality of pain: ache/burn/cramping/dull/prick/sharp/stabbing/throb Please rate your pain Nutrition Are you on a special diet? Yes/No Type of diet Have you had any recent unexpected change in your weight? Yes/No Do you have any trouble swallowing? Yes/No Do you take any nutritional supplements? Yes/No Type of supplement Do you have any cultural or religious restrictions on your diet? Yes/No Type of restrictions Living arrangements Who do you live with? Do you live in a house/apartment/assisted living/nursing home/other? If you answered other, please describe Page 4 of 6
5 Do you require assistance with any of the following daily activities: Getting dressed? Yes/No Going to the bathroom? Yes/No Bathing? Yes/No Grocery shopping? Yes/No Preparing meals? Yes/No Eating? Yes/No Dressing changes? Yes/No Taking medications? Yes/No Do you drive or have access to reliable transportation? Yes/No Do you use adaptive devices at home, such as any of the following: Cane or crutches? Yes/No Walker? Yes/No Wheelchair or motorized scooter? Yes/No Shower chair? Yes/No Other adaptive device? Yes/No o Please describe Work and personal Do you currently work? Yes/No Type of work Will this treatment have an impact on your work? Yes/No Please describe What is your current activity level? Have you fallen recently? Please list any injuries received from falling Do you have any spiritual or cultural preferences that could affect your care? Yes/No Please describe Page 5 of 6
6 Psychosocial history Have you been emotionally or physically abused? Yes/No Has anyone forced you to have sexual activities? Yes/No Are you currently afraid of your partner or anyone else who lives with you or helps to take care of you? Yes/No Do you smoke? Yes/No If yes, how much and when did you start? Do you drink alcohol? Yes/No If yes, how much and how often? Do you use recreational drugs? Yes/No Vaccinations Please list approximate dates for any of the following vaccinations you may have received: Hepatitis A Hepatitis B Influenza Pneumococcal Measles, Mumps, and Rubella Tetanus and Diptheria Chicken pox Page 6 of 6
Medical History Form
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ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
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