ALLERGIES. If yes, please list the food and non-medication (i.e. latex) allergies and type of reaction you had: MEDICATIONS
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1 Name: Birthdate: What is your main health concern today? Do you currently use tobacco? YES NO Have in the past? YES NO Year Quit If yes, what kind of tobacco?_number of years: Amount of tobacco per day: Have you ever tried to quit? YES NO Are you interested in quitting? YES NO Do you drink alcohol? YES NO If yes, what kind? On average, how much do you consume? How often? drinks/week Over the past 2 weeks, have you felt: Little interest or pleasure in doing things? YES NO Feeling down, depressed or hopeless? YES NO ALLERGIES Do you have any food or non-medication allergies? YES NO If yes, please list the food and non-medication (i.e. latex) allergies and type of reaction you had: Food: Reaction: Do you have allergies/adverse reactions to medications: YES NO If yes, please list the medication and the type of reaction you had: Medication: Reaction: MEDICATIONS What is the name of the pharmacy you get your prescriptions filled at? What is the location of that pharmacy?_ Please list your medications, including prescriptions, vitamins, over-the-counter medications and herbal supplements. Please include dose/medication strength and how often you take each medication: Medication Pill/Medication Strength How Often _ 1
2 IMMUNIZATION HISTORY Check the box below for what immunizations/vaccines you have received and the date: Influenza (flu) date: Varicella (chickenpox) date: Shingles (Zoster) date: Tetanus (TD or Tdap) date: Pneumonia and date: PAST MEDICAL HISTORY Please mark a X next to the condition you currently have or have had in the past and the year of diagnosis: Condition Year of Diagnosis High Cholesterol High Blood Pressure Asthma Migraines Heart Disease Heart Attack Stroke Diabetes Thyroid Disease COPD/Emphysema Reflux/GERD/heartburn ADD/ADHD Depression Anxiety disorder Bipolar disorder Other Mental Health illness: Cancer Type of cancer: Other conditions: Have you been admitted to the hospital, other than childbirth, for any reason? YES NO Please list any major or minor surgical procedures and hospitalizations: DATE TYPE OF SURGERIES AND HOSPITALIZATIONS 2
3 Please mark a X next to the diagnostic tests you have had done: Test Date of test Results of test (normal/abnormal) Colonoscopy Treadmill/Stress test Mammogram CT scan MRI DEXA/bone scan Pelvic Exam Sleep Study Endoscopy EKG GYNECOLOGY AND OBSETRIC HISTORY (FEMALES ONLY) Age of first period: Age of menopause: Date of last period: Date of last Pap smear: Have you ever had an abnormal Pap smear? YES NO If yes, what type of treatment did you receive? _ What method of contraception (birth control) do you use (mark a X next to the correct method): Birth control pills and type IUD Depo Implanon Nuva Ring Patch Condoms Tubal Ligation and Date: Husband/Partner Vesectomy How many times have you been pregnant? How many children do you have? Have you had any of the following (mark a X next to the correct event) and indicate how many you have had: Miscarriage How many? Abortion (Spontaneous or Induced) How many? Ectopic Pregnancy How many? Number of full-term deliveries: Number of pre-term deliveries: Number of c-sections: 3
4 FAMILY HISTORY Were you adopted? YES NO (If birth family history unknown, please skip this section) For the following, please indicate any diagnosis/conditions your family has had or did have. Indicate the age of diagnosis or age of death. If family members are alive and well, please mark a X in the alive and well box. Condition Father Mother Sister(s) Brother(s) Other relative Alive and Well Heart Disease Heart Attack Stroke Diabetes High Blood Pressure High Cholesterol Asthma Thyroid Disease Cancer Alcoholism Depression Alzheimer s Disease/Dementia Age of onset or death Mental Illness Other Condition not listed SOCIAL HISTORY Marital Status: Single Married Separated Divorced Widowed Other Do you have children? YES NO # of boys: # of girls: Highest level of education completed: Grade School High School Trade/technical school College Advanced Degree: 4
5 Occupation: If retired, when: Hobbies: Do you exercise? YES NO How many days per week? Type of exercise: Do you use marijuana, recreational or intravenous drugs? YES NO If yes, what type of drug? How often?_ If you ride a motorcycle or bicycle, do you wear a helmet? YES NO Do you use seatbelts regularly? YES NO Do you use sunscreen regularly? YES NO SYMPTOMS AND CONCERNS Please mark a X next to any symptoms or concerns you are currently or have experienced in the past: YES NO Any skin problems? Any suspicious skin lesions? Any eye problems? Glaucoma or persistent eye pain? Wear contact lenses or glasses? Any hearing or ear problems? Frequent nose bleeds, recurrent sinus pain or congestion? Any dental disease or wear dentures? Any trouble breathing, shortness of breath, chronic cough? Any unusual hoarseness? Ever exposed to tuberculosis or have positive skin test or chest x-ray? Do you develop chest pain with exertion? Frequent swelling of feet? Ever blood clots in legs or lungs? Ever rheumatic fever? Does walking cause pain in the legs? Any problems with digestion or movements? Difficulty swallowing? Heartburn or nausea? Ever had an ulcer? Any problems with urination? Trouble emptying bladder, leaking urine? Ever had a kidney stone? Any arthritis or joint pain? Where? Recurrent back problems? Other bone or joint problems? Troubled by headaches? Ever lost consciousness or had seizure? Any trouble sleeping? In the last year, any unexplained change in weight? Unusual heat or cold sensitivity? 5
6 NO SEXUAL HISTORY YES Any prior sexually transmitted infections? Are you concerned about your risk of HIV (AIDS)? Ever have same-sex sexual activity? Any unusual vaginal discharge or itching? Any symptoms of menopause? Any lumps or pain of the testicles? Any problems with erections or sexual intercourse? Any questions about when or how to examine your testicles? NO QUESTIONS FOR THE ELDERLY YES Have you fallen recently? Would you like to discuss a living will? Do you have an advance directive? Have there been special stresses in your life recently? 6
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