Medical History Intake Form
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- Ashlee Benson
- 5 years ago
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1 Medical History Intake Form What is your opinion of your overall level of health? Excellent Good Fair Poor In your opinion (not necessarily your health care providers), what are your most important health care problems. Please list your concerns in their order of importance to you: 1) 2) 3) 4) 5) What do you think might have caused your chief complaint and what other, possibly unrelated events, occurred around the time your chief complaint began? What experiences in your life have affected you deeply from which you have never fully recovered? What secrets did you have to keep as a child? Childhood illnesses: Disease When Disease When Rubella Mumps Measles Chickenpox Page 1 of 8
2 Whooping cough Asthma Scarlet fever Polio Rheumatic fever Other Have you had the following immunizations: DPT MMR HIB Polio Smallpox Flu TB Pneumovac. Other Did you any adverse reactions or chronic illnesses following immunization? If yes, what Have you had any of the following illnesses or medical conditions: Now Past Never Now Past Never Allergies Colitis Anemia Diarrhea Arthritis Convulsions Gout Depression Hepatitis Diabetes Alcohol Abuse Liver disease Anorexia Obesity Asthma Hypertension Bleeding Kidney disease Easy bruising Lung disease Tumors Eczema Seizures Thyroid disease Drug abuse Constipation Cancer Pneumonia Chronic infections Psychosis Drinking problem Rheumatism Crohn's disease Epilepsy Bulimia Migraines Psoriasis Stomach ulcers Herpes Heartburn AIDS Headache Gonorrhea Swelling (edema) Syphilis Hemorrhoids Acne Glaucoma Major trauma Cavities Page 2 of 8
3 Hospitalizations: Illness/surgery Date Where Do you use any of the following foods, drugs, or medications: Coffee Birth Control Pills Cigarettes Alcohol Aspirin Laxatives Sedatives Vitamins Thyroid replacement Hormones Herbal products Chinese herbs Tea Electric blankets Recreational drugs List all of the prescription medication you are presently taking List all of the dietary supplements, herbs, and other medication you are presently taking Do you have allergies to any medications? Family History: Please list the ages of the following family members. If they are deceased please list any major illnesses they might have had (cancer, asthma, tuberculosis, heart attacks, etc.) Relation Living Died Cause of Death or Major Illnesses Mother Father Page 3 of 8
4 Brother(s) Sister(s) Mat. grandmother Mat. grandfather Pat. grandmother Pat. grandfather Has anyone in your family (blood relatives) had the following illnesses: Allergies Anemia Arthritis Asthma Bleeding Cancer Hay fever HBP Seizures Stroke Diabetes Eczema Glaucoma Psoriasis Depression Tuberculosis Do you have now or have you had any of the following symptoms? ( Please grade the symptoms on a scale from 1 to 5, with 1 being mild and 5 severe ) Mental symptoms depression/sadness insomnia increased irritability excessive worry nightmares indifference/apathy mood swings hallucinations feelings of euphoria impatience mental mistakes (dyslexia, etc.) difficulty concentrating restlessness violent temper nervousness fears Please elaborate on any fears that you may have, both general fears and specific fears (animals, places, situations, people, etc.) General symptoms warm-blooded person cold-blooded person Page 4 of 8
5 thirsty thirstless excessive perspiration worse in humidity worse in the wind worse in the cold sensitive to noise worse in the heat worse from changes in the weather periodic symptoms Endocrine or hormonally related symptoms increased hair growth internal chilliness cold hands or feet weight gain internal heat swelling in extremities weight loss increased thirst night-time urination prefer cold weather prefer hot weather weakness chronic fatigue increased appetite decreased appetite depression increased sweating absence of sweating Skin symptoms Rough skin, dry skin (circle) skin infections Itchy skin hives or urticaria Rashes nail changes Moles, warts, cysts (circle) hair loss pimples boils herpes discoloration Head symptoms dizziness fainting spells seizures/epilepsy head injuries headaches migraines hair loss heaviness Eye symptoms poor eyesight double vision Page 5 of 8
6 aversion to light aversion to the sun have to wear sunglasses infections styes itchy eyes Ear symptoms discharge from the ears chronic ear infections pain in the ears hearing loss ringing in the ears itching in the ears Nose symptoms nose bleeds sinus infections loss of smell breathing problems Mouth/teeth symptoms gum infections canker sores/aphtha fever blisters cracked lips bad breath increased salivation loss of teeth many cavities Neck/Throat symptoms persistent hoarseness throat pain difficulty swallowing chronic infections loss of voice swelling stiffness injuries Cardiovascular/Respiratory symptoms wheezing persistent cough night sweats chronic infections difficulty breathing shortness of breath Page 6 of 8
7 have to sit up in bed at night chest pain when walking ankle/leg swelling high blood pressure heart palpitations leg pains chest pain at rest Digestive symptoms heartburn bloating gas pain diarrhea constipation blood in stools increased appetite loss of appetite food cravings rectal itching hemorrhoids belching indigestion after meals diarrhea & constipation overweight stomach ulcers hiatal hernia yellow or clay colored stools straining at stools rectal itching hemorrhoids Do you have a strong desire for any particular foods? Do you an aversion to any foods? Are there any foods that make you feel bad or aggravate any of your symptoms? Urogenital system frequent urination painful urination pain at the end of urination difficulty urinating involuntary urination blood in the urine Male prostate problems discharges Page 7 of 8
8 painful erections difficulty with erections infertility swelling in the testicles Female vaginal discharges painful intercourse few or no orgasms cervical problems infertility itching in the vagina Menses PMS irregular periods excessive bleeding miscarriages excessive menstrual flow bleeding between menses When did you begin menstruating? How long do your periods last? Number of pregnancies Number of births Miscarriages Abortions Complications during pregnancy? Did you breastfeed your children? Musculoskeletal symptoms muscle pain joint pain pain in the bones numbness/tingling traumatic injuries head injuries Nervous system paralysis convulsions tremor or shaking memory loss numbness twitching insomnia anxiety attacks Please use this space for any further information you wish to provide: Page 8 of 8
Medical History Form
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Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Medical Information. (office use) MRN: CMRN: Last Name: First Name: Middle Initial: Date of birth: Age: Sex: M F Height: Weight:
1835 W. County Rd C, Suite 80, Roseville, MN 55113 P: 651-797-6880 F: 651-797-6881 info@spartzvein.com spartzvein.com Medical Information Date of consultation: (office use) MRN: CMRN: Last Name: First
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
Health History Questionnaire
Health History Questionnaire Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Mobile Phone: Email: Date of Birth: Place of Birth: Height: Weight: Relationship Status: Employer: Single
Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
Please indicate any serious conditions, illnesses or injuries, and any hospitalizations along with approximate dates: Medicines: Environment: Other:
Our health is influenced by many different factors. Your health history provides valuable information to help me understand your current health. Please fill out this form to the best of your ability and
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY: