Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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1 ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT DOSE HOW MANY TIMES PER DAY? Check here if list of medications continues on the back of this paper. Check here if list is attached. ALLERGIES List any allergies to medications: PHARMACY NAME/ADDRESS/PHONE NUMBER: PAST MEDICAL HISTORY Mark ( ) all that apply. Acid reflux disease Chemical dependency High cholesterol/high triglycerides Pneumonia Alcoholism Depression HIV/AIDS Polio Anemia Diabetes Irregular menstrual periods Prostate problem Anorexia Emphysema Kidney disease Psychiatric care Arthritis Epilepsy/seizures Liver disease Stroke Asthma/lung problem Emphysema/COPD Glaucoma Migraine headaches Suicide attempt Bleeding disorders Goiter Miscarriage Thyroid problems Breast lump Gout Multiple sclerosis Tuberculosis Bulimia Heart disease Mumps Ulcers Cancer Hepatitis/liver problems Osteoporosis Osteopenia Broken bones Vaginal infections Cataracts High blood pressure Pacemaker
2 Check here if list of Past Medical History continues on the back or separate paper is attached. SURGICAL/HOSPITALIZATIONS HISTORY List past surgeries/hospitalizations and years. Surgery/ Hospitalization Year Check here if list continues on back or separate paper with list is attached. FAMILY HISTORY Complete health information about your family. RELATION AGE AGE at DEATH CAUSE of DEATH MEDICAL CONDITION LISTED BELOW? (YES or NO) Father Mother Brothers Sisters Check the diagnoses below if any of your blood relatives has or had these conditions. If so, please state the person s relationship to you: CONDITION Diabetes Thyroid disease High blood pressure Heart disease Stroke Breast cancer Ovarian cancer Prostate cancer Kidney stones Osteoporosis High cholesterol Which of your above relatives has or had this?
3 IMMUNIZATIONS: When was your last pneumonia vaccine? Never had When was your last flu vaccine? Never had SOCIAL HISTORY Mark ( ) all that apply. Marital Status: Single Married Separated Divorced Widowed Living Situation: Alone Partner Parents Children (# of children ) Nursing Facility Occupation: Job Title Retired Unemployed Student Exercise: Type of exercise How often in one week: Do you smoke? Yes No Never If yes, how much? Do you drink Alcohol? Yes No If yes, about how much? Recreational drugs used: Hobbies/relaxation: FOR WOMEN ONLY: How old were you when you had your first menstrual cycle? Are your cycles regular? Yes No Date of the beginning of your last menstrual cycle How many times have you been pregnant? Did you have difficulty getting pregnant? How many children have you had? How many miscarriages? FOR DIABETES PATIENTS ONLY: What year were you diagnosed with diabetes? How old were you when diagnosed? Have you ever been hospitalized for high blood sugars? When and where? When was your last eye exam? If on insulin therapy, how long have you been on insulin? Can you feel when your blood sugar is low? Have you ever required the assistance of others to raise your blood sugars after a low blood sugar episode? If so, please describe: How often do you check your blood sugars at home If you have an insulin pump, what pump is it? How long have you been on an insulin pump?
4 If known, please report: Insulin to carbohydrate ratio: Sensitivity: Insulin active time: Blood sugar goal: Please document your pump s current basal settings on the back of this paper. During the past month, what have your blood sugars been: Pre-breakfast (fasting) Pre-lunch Pre- dinner Bedtime HIGHEST LOWEST AVERAGE **PLEASE ENSURE THAT YOU BRING YOUR LOGBOOK AND GLUCOMETER TO YOUR APPOINTMENT.** REVIEW OF SYSTEMS SYMPTOMS Mark ( ) symptoms that pertain to you. GENERAL: Fever Chills Sweats Weight gain Weight loss Loss of appetite Excessively tired Heat or cold intolerance SKIN/HAIR/NAILS: Skin rash Dry skin Change in hair or nails Poor wound healing Excessive perspiration Itching EYES: Eye pain Vision blurring Double vision Vision loss Eye redness Eye infection EARS/NOSE/ MOUTH/THROAT: Ringing/buzzing in ears Loss of hearing Ear pain Nasal congestion Loss/lack of smell Frequent nose bleeds Hoarseness Sore throat Difficulty swallowing Swelling CARDIOVASCULAR: Chest pain/pressure Irregular heart beat Loss of consciousness Swelling of hands/feet Shortness of breath Palpitations Leg cramps when walking GASTROINTESTINAL: Vomiting Nausea Diarrhea Constipation Change in bowel habits Stomach pain Indigestion/Heart burn Rectal bleeding/bloody stools RESPIRATORY: Cough Shortness of breath Snoring Coughing up mucous Coughing up blood Wheezing GENITO-URINARY: Painful urination Poor bladder control Blood in urine Frequent urination Difficulty urinating Decreased sex drive WOMEN ONLY: Vaginal discharge Absent menstrual period Irregular menstrual period Breast lump/discharge Menstrual pain/cramps MEN ONLY: Erection difficulties Testicular lump/pain Penile discharge MUSCULOSKELETAL: Back pain Joint pain Muscle cramps Muscle weakness Arthritis Stiffness of the joints NEUROLOGIC: Memory loss Seizures Dizziness Temporary paralysis Tremors Loss of Consciousness Numbness/Tingling Headache PSYCHIATRIC: Depression Anxiety Paranoia Suicidal thoughts Hallucinations ENDOCRINE: Cold intolerance Heat intolerance Frequent thirst Increased hunger
5 Increased urination Weight loss or gain HEME/LYMPHATIC: Slow wound healing Abnormal bruising Bleeding difficulties Enlarged lymph nodes ALLERGIC/IMMUNOLOGIC: Skin conditions Hay fever Persistent infections HIV exposure
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/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE PLEASE PRINT Full name: Age: Preferred Contact number: Email address: Why are you here today? To establish primary care Annual exam Consultation from another doctor If consultation,
Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5
Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact#: Alternate#: Work#: Date of Birth: / / Sex: Male Female SS# (optional): Marital Status : Single Married Divorced