Medical History Form
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- Shawn Rogers
- 6 years ago
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1 Medical History Form Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best care possible to our patients. Feel free to use additional pages to write any information not included here that you think is important. Current/Past Medical Problems: Example Strokes, Heart trouble, High Blood Pressure, High Cholesterol, Thyroid Problems, Eye problems, etc Current or Past Medical Problem Approximate date of onset or diagnosis Past Surgeries: Example Gall Bladder removed, Appendectomy, Hysterectomy with or without ovaries removed, Cataract surgery, Prostate surgery, Heart surgery, Angioplasty, Colonoscopy, etc. Past Surgery Approximate Date of Surgery Medical Allergies and reaction: Example rash, swelling, trouble breathing, etc. Medicine Allergic To Reaction
2 Medications: Please list both prescription and over the counter medication (such as pain relievers, constipation medicine, heart burn medicine, vitamins, etc.) and how many times a day medication is taken. For as needed medication please give an estimate of how often you take it such as once every other day, once a week, once or twice a month, etc. Add another sheet with additional medications if necessary. Medication and Strength (mg or mcg, etc.) How Often Taken Local Pharmacy: ; Phone #: Mail Order Pharmacy: ; Phone #: Member ID #: ; Fax #: 6. Family History: Please list medical problems of close family members (example Dementia, Cancer and what type, Heart disease, Stroke, Diabetes, Hypertension, Depression, etc.), if anyone has died, the age of death and the cause of death. Underneath Mother list any brother(s)/sister(s) and their medical problems. Family Member Age Died Cause of Death or any Medical Problems Father Mother 2
3 6. Social History: Lives with: Married: ; Widow(er): ; Divorced: ; Single: Who is the primary caregiver and are there other caregivers involved: How do you get transportation and how often and for what purpose do you leave the house? Smoking: Never ; How many years smoked: ; How many packs per day on average: ; What age did you quit smoking: Alcohol Use: Never ; How often and how many alcohol drinks do you have now and in the past? Was drinking too much alcohol ever a problem for you? Past Occupation(s): What was the highest level of education completed: Ever used street drugs or overused prescription drugs: Religion/Faith: ; Is your faith important to you and does it affect your health care decisions: Do you have Advance Directives: Yes ; No ; Unsure. Would you like information on Advance Directives: Yes ; No I have a: Living Will ; Durable Power of Attorney for Health Care (Name and relationship of POA: ); Do Not Resuscitate Form If you have any of the above documents please have a copy of them made for us to place in their chart. 7. Activities of Daily Living: Please mark or fill in the appropriate box below. Activities of Daily Living Feeding Bathing Toileting Dressing Transferring Walking No Assistance Total Assistance Needs Some Partial Assistance: Please Describe 8. Medicare Home Health Agency: Yes ; No ; Name: ; Phone #: ; Nurse: Yes ; No ; Physical therapy: Yes ; No ; Occupational Therapy: Yes ; No ; Speech Therapy: Yes ; No 3
4 9. Review of Systems: Please check or describe below any of the following symptoms you may be having: General: Decreased Appetite ; Fevers or Sweats Height: Feet inches; Any loss of height: inches Weight: pounds (Can estimate); Please list weight loss or gain approximately pounds over the past months. Eyes: Decreased Vision ; Double Vision ; Last eye exam: Ears, Nose, Throat, Mouth: Hearing Loss ; Hearing Aide ; Runny Nose ; Sinus Problems ; Dentures ; Swallowing problems ; Last dental exam: Cardiovascular: Chest pain ; Do you have to prop yourself up to breath comfortably at night Respiratory: Shortness of breath ; Trouble Breathing when you exert yourself ; Coughing ; Wheezing Gastrointestinal: Nausea ; Vomiting ; Diarrhea ; Constipation ; Abdominal pain ; Heart burn ; Blood in stool Genitourinary: Urinary frequency ; Burning ; Intermittently losing urine or wetting pants ; Completely incontinent ; Nighttime urination episodes: Musculoskeletal: Joint pain (Location: ); Joint swelling ; Weakness arms ; Weakness legs ; One sided weakness from stroke Skin: Rash (Location: ); Bed sore ; Location of bedsore and type of dressing: ) Neurologic: Seizures ; Falling ; Memory loss ; Confusion ; Numbness ; Tingling ; Dizziness ; Trouble sleeping Psychiatric: Depression ; Anxiety ; Lack of motivation ; Suicidal thoughts Endocrine: Heat intolerance ; Cold intolerance ; Hot flashes ; If diabetic how many times a day glucose checked: ; Morning glucose range: ; Evening glucose range: Hematology/Lymphatics: Easy bruising ; Leg swelling Allergy/Immunology: Environmental Allergies ; Hay fever ; Allergies to foods What are your main concerns you would like to have addressed when we come to see you and are there any other problems not discussed above: 4
5 9. Immunizations: Please mark the appropriate box below and list dates if known. If not known please contact your primary care doctor before our visit and ask if you are up-to-date on your immunizations. Immunization Yes Date No Unknown Refuses Influenza (Flu) Pneumococcal (Pneumonia) 10. Durable Medical Equipment: Please list any medical equipment you have in the home such as a bedside commode, wheel chair, walker, hospital bed, tube feeding pump, suction machine, etc. Please also list the name of the medical supplier and their phone number. Name of Equipment Supplier Name Supplier Phone # 1 Recent Hospitalizations: Please list the reason for any recent hospitalizations in the past 2 years and the hospital you were in. Reason for Hospitalization Name of Hospital Date 1 Recent Doctors: Please list any recent doctors, their specialty (e.g. Primary doctor, cardiologist, neurologist, etc.) and their phone number and fax number. Doctor Name Specialty Phone Fax Please fax this information to NOVA HouseCall Physicians office at
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NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )
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