Patient History Form
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- Naomi Patrick
- 6 years ago
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1 Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name: Are we authorized to discuss medical information with your spouse? Anyone else? If so, whom Do you have any children? Child's name(s): Do we have permission to leave test results on your home answering machine if you are not available? List All Medication Allergies and Reactions List all Current Medications You Are Taking ITEM # Page 1 of 8
2 . Have you received any health care elsewhere in the last year? If yes, please list, including physicians, urgent care, therapists, chiropractors, outpatient tests. Date Provider or Site Reason PERSONAL HABITS Do you have a living will? Do you have Power of Attorney? Do you wear seat belts? Do you exercise regularly? Type Do you chew tobacco? Do you drink alcohol? Check the type of alcohol consumed Do you now or have you ever smoked? If you have quit, how long ago? Are you exposed to secondhand smoke? Do you use illicit drugs? Do you feel you have a dependency on any prescription drugs? (if yes, please provide copy) (if yes, please provide copy) times per week packs per week for years beer wine liquor packs per week for years PAST MEDICAL HISTORY 1. Indicate any operations that you have had. Give date if known. 2. Indicate any hospitalizations for non-surgical illnesses. Give date if known. ITEM # Page 2 of 8
3 3. Have you ever had any of the following? Check all that apply. alcohol/drug dependency asthma or hay fever blood transfusion cardiac arrhythmia depression gallbladder disease heart disease high blood pressure HIV skin disease ulcers Other: anemia back trouble bone disorder colitis diabetes heart attack hemorrhoids jaundice osteoporosis stroke / TIA varicose veins anxiety / panic disorder bleeding disorder breast problems colon polyps diverticulitis heart failure hepatitis / liver disease kidney stones pneumonia thyroid disease arthritis blood clots or phlebitis cancer convulsions/ seizure emphysema heart murmur hernia migraines sexually transmitted disease tuberculosis 4. Indicate any major childhood illnesses: 5. When was your last physician exam? Include date and provider. If you have had any of the following, please indicate date: Date Flu shot Chest x-ray Hepatitis B vaccine Dental exam Pneumonia vaccine EKG TB skin test / PPD Eye exam Tetanus vaccine Mammogram (last) Cholesterol screen Stress test Colonoscopy Date ITEM # Page 3 of 8
4 For WOMEN only: Date of your last menstrual period: Are you menopausal? If yes, date of onset: Have you taken estrogen replacement? If yes, how long have you been on replacement therapy? When did you begin this therapy? Number of pregnancies: Number of live births: Number of miscarriages or abortions: Date of last Mammogram / never Have you been instructed in proper self breast exam technique? Do you perform self-breast exams? For MEN only: Do you practice regular self-exams? FAMILY HISTORY UPDATE If living If deceased FATHER MOTHER GRANDFATHER (FATHER SIDE) GRANDMOTHER (FATHER SIDE) GRANDFATHER (MOTHER SIDE) GRANDMOTHER (MOTHER SIDE) BROTHER OR SISTER Age Health Age Cause of Death ITEM # Page 4 of 8
5 Has any blood relative developed any of the following in the past year? Please Check: Alcohol Abuse Alzheimer's Disease Aneurysm Cancer / Breast / Kidney / Ovarian / Prostate / Other Colon Polyps Diabetes Epilepsy Heart Disease High Blood Pressure Kidney Disease Melanoma Stroke Who: Listed below are specific symptoms or conditions you may have had trouble with in the past year, or you may be having trouble with now. They are grouped into body systems such as skin, eye, abdominal organs, etc. Please read each system in its entirety before answering. If you have had no problems with any of the symptoms listed under a given heading, check NO next to the system title. If you are having problems, then check the YES next to the specific symptom. GENERAL HEALTH NOSE AND SINUSES fever night sweats frequent nose bleeds hay fever hot flashes significant weight gain sinus congestion MOUTH AND THROAT ITEM # Page 5 of 8
6 significant weight loss sores in mouth loss of appetite ENDOCRINE GLANDS goiter (enlarged thyroid) problems with tonsils hoarseness LUNGS overactive thyroid cough underactive thyroid coughing up blood excessive thirst shortness of breath excessive hunger SKIN get winded easily emphysema rash chronic bronchitis sores wheezing boils eczema moles (that have changed color or size) LYMPH GLANDS positive tuberculin skin test HEART AND BLOOD VESSELS chest pain chest discomfort swelling in the neck wake up short of breath swelling in the armpit rapid heartbeat swelling in the groin EARS difficulty hearing irregular heart beat heart murmur rheumatic fever drainage from ears palpitation (heart thumps) frequent ear infections swelling in ankles pain in ears vein problems in leg EYES wear gasses or contacts eye pain.. cramps in legs when walking ABDOMINAL ORGANS abdominal pain glaucoma bloating after meals sudden changes in vision heartburn / indigestion double vision ulcers blurred vision vomiting blood blind spots liver disease ITEM # Page 6 of 8
7 KIDNEYS OR BLADDER difficult / painful urination blood in urine cannot hold urine. jaundice hepatitis gallstones frequent use of antacids very frequent urination heavy drinking get up more than once at night to urinate frequent infections difficulty swallowing constipation kidney disease kidney stones protein in urine sugar in urine MUSCLES, BONES, JOINTS deformities muscle weakness. recent change in bowel habits blood or mucus in stool black, tarry stool hemorrhoids rectal pain GENITALS - WOMEN date of last menstrual period pain in joints date of last Pap smear chronic pain in back birth control method swelling in joints gout do you know how to examine your breasts? This past year have you had: NERVOUS SYSTEM frequent/ severe headaches abnormal Pap smear unusual vaginal discharge. head injury seizures/ fits/ convulsions irregular period abnormal bleeding epilepsy numbness or tingling pain with intercourse pelvic pain weakness breast lumps difficulty sleeping suicidal thoughts nipple discharge venereal disease ITEM # Page 7 of 8
8 severe anxiety GENITALS - MALE sores on penis discharge from penis prostate gland trouble difficulty urinating impotence venereal disease Do you do self testicular exams? Patient Signature Date Time AM / PM ITEM # Page 8 of 8
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Medical History Form
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
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Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work)
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
Personal Health Risk Appraisal
Today s Date: Premier Arthritis and Osteoporosis Center 722 North Fairfield Road Beavercreek, OH 45434 Phone (937) 208-7000 Fax (937) 208-7010 Personal Health Risk Appraisal Last Name: First Name: MI:
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
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL