HD CLINIC MEDICAL HISTORY FORM

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1 HD CLINIC MEDICAL HISTORY FORM Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the questions below as best as you can. If you need assistance, a caregiver/companion may complete this form for you. Appointment Date: DEMOGRAPHICS: Date of Birth: Height: Please answer the following questions: Current Weight: Are you Right Handed? Are you Left Handed? Education Completed: Grade (K-12) College Graduate school Degrees Employment: Full-Time Work Number of years: Degree: Please list: Number of Hours per week: Full-Time Occupation Part-Time Work Number of Hours per week: Part-Time Occupation Unemployed Date you last worked: Occupation at last job: Applied for OR Receiving Disability Benefits Please describe type (Social Security, etc) 1

2 Marital Status: Single Married Divorced With partner FAMILY HISTORY: Mother Maternal Grandmother Maternal Grandfather Father Paternal Grandmother Paternal Grandfather Siblings (list name and age) Children (list name and age) Are they living? Other persons affected with HD in your family not listed above? How long? How long? How long? Are/were they affected with HD? 2

3 CURRENT MEDICATIONS: Please list all current medications, either prescribed or over-the- counter (may attach list if you have brought one) Please list any known allergies: (i.e. Medication, Food, Environmental, etc.): SOCIAL HISTORY: Do you live alone? If no, with whom do you live? Do you exercise regularly? Please describe the exercise you participate in? Be sure to include how often. Do you drink alcohol? --Number of drinks per week? How often? Do you smoke cigarettes, tobacco, pipes or cigars? --How long have you been smoking? Number of packs/cigars per day? Do you use cannabis (marijuana) or any recreational drugs? If yes, please list: 3

4 PAST MEDICAL/SURGICAL HISTORY: Have you ever been diagnosed with any of the following? High blood pressure Diabetes Heart Attack Stroke Heart Failure Blood vessel disease High cholesterol or lipids Tuberculosis Immunodeficiency disorder Hepatitis Cancer Respiratory illness Bleeding problems Leg clots Peptic Ulcer disease Kidney or urinary problems Arthritis Skin conditions Seizures Traumatic Brain Injury For women, any gynecologic issues? For men, any prostate or urologic issues? Have you ever had an injury or illness requiring hospitalization: If so, describe Date Diagnosed? Have you ever had surgery? Please list year(s) and reason for surgery(s)? 4

5 For Females: Have you ever been pregnant? --Number of Pregnancies --Number of Deliveries Any complications due to pregnancy? Are you still capable of pregnancy? Please describe? Are you using any form of birth control? Year of Menopause? MENTAL HEALTH HISTORY: Have you ever received medicine, counseling or been hospitalized for: Depression Anxiety Obsessive Compulsive Disorder Psychosis Suicidal Thoughts Suicidal Attempt REVIEW OF SYSTEMS: Have you been diagnosed with HD? What year were you diagnosed and where were you diagnosed? What were your FIRST symptoms? Motor (movement problems) Cognitive (thinking problems) Psychiatric (mood or behavioral problems) Mixture of the above symptoms Other symptoms What age did you FIRST experience symptoms What symptoms did your affected parent have and at what age did they occur? 5

6 Please answer YES or NO for the following questions: General: Weight Gain/Loss of more than 5 lbs over the last several months? Loss of Appetite? Fever or Chills? Feel weak and tired? Skin: Do you have rashes, bruises? Skin Discoloration? Bleeding/easy bruising tendency? Head: Do you have tenderness? Lumps or masses? Eyes Pain or discharge? Change in Vision Respiratory: Short of breath on exertion? Walk 2 flights of stairs w/out significant discomfort? Have frequent yellow/green sputum? Cough up blood? Cardiovascular: Chest pain, tightness, angina of the chest on exertion? Chronic ankle swelling? Can you sleep flat in bed? Do you wake up at night short of breath? Gastrointestinal: Nausea or vomiting? Diarrhea or constipation? Black tarry stools or bloody stools? Heartburn or reflux? Ears: Hearing problems? Pain or discharge se: Frequent nose bleeds? Trouble breathing through nose? Pain or discharge? Mouth & Throat: Dental Disease? Hoarseness or voice changes? Sore throat or other pain? Lumps, masses, discharge? Genitourinary: Cloudy or bloody urine Burning on urination Get up several times at night to urinate? Men: Hard to initiate/maintain urination? Central Nervous System: Any seizures? Severe headaches? Loss of strength or sensation? Memory changes? Other neurologic problems? Arthritis or joint problems? 6

7 PRIMARY CARE DOCTOR: Address: Contact Phone Numbers: PSYCHIATRIST OR PSYCHOLOGIST: Address: Contact Phone Numbers: NEUROLOGIST: Address: Contact Phone Numbers: 7

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