SCHNEIDER MEDICAL GROUP, PA History Intake Form (Please Print)
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1 History Intake Form Patient Name: Date of Visit: Briefly State the reason for the visit: Date of Birth: Physician Use Only - History and Present: Page 1 of 10
2 Review of Symptoms HEAD NO YES EXPLAIN Eyes Blindness Cataracts Glaucoma Wear Glasses EARS NO YES EXPLAIN Hearing aids Nose Sinuses Allergic rhinitis Sinus infections MOUTH/THROAT/TEETH NO YES EXPLAIN Dentures CARDIOVASCULAR NO YES EXPLAIN Aneurysm Angina DVT Dysrhythmia/irregular heart rhythm Hypertension Murmur Myocardial infarction Other Heart disease RESPIRATORY NO YES EXPLAIN Asthma Bronchitis/emphysema Pleuritic Pneumonia Page 2 of 10
3 Review of Symptoms NEUROLOGICAL NO YES EXPLAIN Epilepsy Seizures Severe headaches, migraines Stroke TIA ENDOCRINE NO YES EXPLAIN Goiter Hyperlipidemia Hypothyroidism Thyroid disease Thyroiditis Diabetes mellitus type 1 Diabetes mellitus type 2 HEME/ONC NO YES EXPLAIN Anemia Cancer INFECTIOUS NO YES EXPLAIN HIV STDs Tuberculosis (diagnosis) Tuberculosis (expossure) CUSTOM ITEMS NO YES EXPLAIN Irritable bowel syndrome Obesity Skin cancer Colitis Colon polyps Rare cancer Other Page 3 of 10
4 Review of Symptoms GASTROINTESTINAL NO YES EXPLAIN Cirrhosis GERD Gallbladder disease Heartburn Hemorrhoids Hepatitis Hiatal hernia Jaundice Ulcer GENITOURINARY NO YES EXPLAIN Hernia Incontinence Nephrolithiasis Other Kidney disease STDs UTIs MUSCULOSKELETAL NO YES EXPLAIN Arthritis Gout Musculoskeletal injury Fibromyalgia SKIN NO YES EXPLAIN Dermatitis Moles Other Skin Conditions Psoriasis Eczema Page 4 of 10
5 Past Medical History CHILDHOOD DISEASES NO YES YEAR Measles Mumps Rubella Chicken Pox Whooping Cough Menengitis Pneumonia Asthma Eczema Chronic Allergies Other: HAVE YOU EVER HAD/BEEN DIAGNOSED WITH: Hypertension NO YES WHEN Diabetes: Adult Onset or Insulin Dependent Cholesteral Problems Cancer TB Diverticulosis Ulcer Disease Inflamatory Bowel Disease: Ulcerative Colitis or Crohn s Disease Irritable Bowel Syndrome Gluten Sensitivity Thyroid Disease: overactive or underactive Cardiac Disease: Mitral Regurgitation or Angina Asthma COPD Head Trauma Headaches Stroke Seizures Page 5 of 10
6 Preventive Tests & Vaccines/Immunizations PHYSICAL EXAM NO YES DATE TEST LAST TEST Bone density Colonoscopy Cardiac stress test Hepatitis C Screen HIV screen Mammogram Pelvic and Pap smear PSA EKG Flu shot Pneumovax 23 pneumonia vaccine Prevnar 13 pneumonia vaccine Zostavax or shingles vaccine IMMUNIZATION DATE Tetanus-diphtheria; Tetanus-Diphtheria-Pertussis (TD/Tdap) Pneumococcal Vaccine - Pneumoax 23, Prevnar 13 Influenza TIV LAIV Hepatitis A and B Measles/Mumps/Rubella (MMR) Varicella (Chickenpox) Haemophilus Influenza Type B (Hib) Human Papillomavirus (HPV) Vaccine Tuberculosis (TB), TB skin test Typhoid Zostavax (Shingles Vaccine) YOUR BLOOD TYPE Page 6 of 10
7 HOSPITALIZATION SCHNEIDER MEDICAL GROUP, PA Hospitalization and Procedures History REASON APPROXIMATE Month/Day/Year SURGICAL PROCEDURES REASON APPROXIMATE Month/Day/Year Page 7 of 10
8 Lifestyle History - Social History ALCOHOL NO YES TYPE/AMOUNT/HOW OFTEN/HOW MANY YEARS Do not drink Drink daily Frequently drink History of alcoholism Occasional drink DRUG ABUSE NO YES TYPE/AMOUNT/HOW OFTEN/HOW MANY YEARS IV drug use Illicit drug use No illicit drug use CARDIOVASCULAR NO YES TYPE/AMOUNT/HOW OFTEN/HOW MANY YEARS Eat healthy meals Regular exercise Take daily aspirin SAFETY NO YES TYPE/AMOUNT/HOW OFTEN/HOW MANY YEARS Household smoke detector Keep firearms in the home Wear seat belts SEXUAL ACTIVITY NO YES TYPE/AMOUNT/HOW OFTEN/HOW MANY YEARS Exposure to STI Homosexual encounters Not sexually active Safe sex practices Sexually active TOBACCO/VAPOR NICOTINE NO YES PACK PER DAY/HOW MANY YEARS Current every day smoker Current occasional smoker Former smoker Heavy tobacco smoker Light tobacco smoker Never smoked Smoker, current status unknown Unknown if ever smoked Page 8 of 10
9 Family History GENERAL NO YES RELATIONSHIP ALIVE (AGE) No health concerns DECEASED (AGE) Arthritis Asthma Bleeding disorder CAD less than age 55 COPD Diabetes Heart attack Heart disease High cholesterol Hypertension Mental illness Osteoporosis Stroke CANCER RELATIONSHIP ALIVE (AGE) Breast cancer DECEASED (AGE) Colon cancer Ovarian cancer Uterine cancer Other cancer Page 9 of 10
10 Allergies ALLERGIES: NO YES REACTION Sulfa Penicillin Codeine ACE Inhibitor OTHER DRUGS: Name: Name: ENVIRONMENTAL ALLERGIES: NO YES REACTION Name: Name: PRESCRIPTION MEDICATIONS DOSE TIMES PER DAY STARTED SUPPLEMENTS DOSE TIMES PER DAY STARTED OTC (OVER THE COUNTER) DOSE TIMES PER DAY STARTED FAVORITE DRUG STORE ADDRESS PHONE# FAX# Page 10 of 10
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Salt Lake Orthopaedic Clinic Initial Visit Form
Salt Lake Orthopaedic Clinic Initial Visit Form Name: Today s Date: Date of Birth: Age: Height: Weight: Handedness (R/L): Referring Physician: Primary Care Physician: Chief Complaint Why are you seeing