PRIMARY CARE (719)
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- Leo Ford
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1 PRIMARY CARE (719) Please help us in meeting your health care needs by providing the following information. *Children under 13, please use Pediatric Health History only. Thank you! Patient: Who is your visit with? Today s Date: What is your reason for coming in today? PAST MEDICAL HISTORY: List all medical illnesses you have had, including the date of diagnosis: Illness/Medical Condition: Treated by: Date: List any surgeries you have had, including dates if known: Surgery: Treated by: Date: List any medications you are now taking, including all non-prescription, over-the-counter, vitamins and herbal: Medication: Dose: How Taken: Continued next page Page 1
2 Patient Name: ALLERGIES Drugs/medications: Known food allergies: Have you ever had any of the following health maintenance testing? (If so, enter date or year): Mammogram: Colonoscopy: DEXA (Bone Scan): Chest X-Ray: EKG: PAP: Lab(s): cholesterol blood sugar thyroid other: IMMUNIZATIONS Please list the immunizations you have had, noting the estimated date. Tetanus Polio Pneumovax Hepatitis Shingles Influenza Measles/Mumps/Rubella SOCIAL HISTORY: (Circle one) Marital Status: Single Married Separated Divorced Widowed Use of Alcohol: Never Rarely Moderate Daily Use of Tobacco: Never Previously, but quit Current: packs/day Use of Vapors/E-Cigs: Never Type/frequency: Use of Marijuana: Never Frequency: Use of Drugs: Never Type/frequency: Excessive exposure at home or work to: Fumes Dust Solvents Airborne particles Noise Are you on any special diet? If so, what type of diet? Do you think you eat nutritiously? yes no, why Are you concerned with your weight? no yes Do you exercise regularly? no yes, what type? SEXUALITY: Gender: Male Female How do you identify? Heterosexual Lesbian Gay Transgender Bi-sexual Other Are you sexually active? yes no Any concerns? MEDICAL HISTORY Family Medical History: Mother s Deceased? No Yes, cause of death: Father s Deceased? No Yes, cause of death: Continued next page Page 2
3 Patient Name: CONDITION CIRCLE ONE WHICH FAMILY MEMBER? High Blood Pressure No Yes Heart Disease No Yes Diabetes No Yes Cancer No Yes Kidney Failure No Yes Mental Illness No Yes Alcoholism No Yes Tuberculosis No Yes Thyroid No Yes Are there any other illnesses that run in your family? Menstrual History: How old were you when you started your periods? Are you post-menopausal? no yes, date of last period WOMEN ONLY Are your periods regular? yes no, explain If regular, how many days lapse between your periods (for example, the average cycle is 28 to 32 days) How many days do you flow? Describe flow Do you suffer from menstrual cramps or other menstrual problems? no yes, explain Pregnancy History If you have ever been pregnant, please answer the following: How many children do you have? Number of abortions or miscarriages: Did you have any complications with your pregnancies? no yes, explain Have you had an ectopic pregnancy? no yes, how many? What form of birth control are you using (i.e., Pill, IUD)? Do you have a Living Will and/or Advanced Directives? No Yes (if so, please provide a copy) Would you like information on these documents? No Yes Authorization & Release: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health and it is my responsibility to inform the doctor s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need. Signature of patient (or parent/guardian if minor) Page 3 Date
4 FAMILY MEDICINE MRN: (Office use only) Patient Name: Name child goes by: ALLERGIES: NONE Medication: Food: Environmental: MEDICATIONS: NONE Prescription: Over-the-Counter: DIET: Infant: Breast Formula: Child: Regular Vegetarian Vegan Gluten-free IMMUNIZATIONS: Up-to-Date Behind NONE ACTIVE MEDICAL PROBLEMS: NONE Asthma Allergies ADHD Eczema Diabetic Seizures Ear Infections Bed Wetting Constipation Recurrent UTI Hypertension Concussions Depression Glasses Developmental Delay: Speech Gross Motor Fine Motor Social PAST MEDICAL: Birth History: Vaginal C-section Weight: Term Preterm: weeks Medical History: NONE Hospitalizations: Specialists seen: Other: Continued next page
5 Patient Name: Surgical History: NONE Ear Tubes Tonsils Fractures: Adenoids Appendix Hernia FAMILY HISTORY: NONE Mother Father Sibling Relative Asthma Allergies Diabetes Hypertension Heart Disease Thyroid Disease Cancer ADHD Depression Migraines High Cholesterol SCHOOL AND ACTIVITIES: Daycare Public School Private School Home School Grade: IEP: Yes Sports: Activities: FAMILY STRUCTURE: Parents: Single Married Divorced Remarried Custody: N/A Joint Mother Father Mother s Name: Father s Name: Step-Parents: Siblings:
6 NAME REVIEW OF SYMPTOMS: Please check any of the following if you are currently experiencing symptoms: GENERAL Fever Chills Feeling tired Feeling poorly Weight gain Weight loss EYES Vision problems Red eye Eye pain Eye discharge Dry eyes Itchy eyes ENT Ear pain Hearing loss Nose bleeds Nasal discharge Sore throat Hoarseness RESPIRATORY Short of breath Awaken short of breath at night (PND) Cough - dry Short of breath w/ exertion Hurts to breathe Short of breath lying down Wheezing Cough - productive CARDIO Chest pain Palpitations Lower leg swelling Heart rate slow Lower leg clot Heart rate fast GASTRO Abdominal pain Constipation Heartburn Vomiting Blood in stool Nausea Diarrhea Difficulty swallowing URINARY Pain w/urination Urination at night How often? Hesitancy Loose bladder Control Flank pain Pass kidney stones Pelvic pain REPRODUCTIVE Painful menstrual cycle Vaginal discharge Pain w/intercourse Abnormal vaginal Bleeding Testicular pain Erectile dysfunction Premature ejaculation Genital lesions Decreased libido MUSCULOSKELETAL Joint pain Joint swelling Joint stiffness Limb pain Limb swelling NEUROLOGICAL Headaches Confused Dizziness Fainting Limb weakness Convulsions Difficulty walking Numbness upper extremity Numbness lower extremity INTEGUMENTARY Skin lesions Skin wound Itching Change in mole Skin rash Dry skin Breast pain Breast lump PSYCHIATRIC Depression Suicidal Anxiety Sleep disturbances Personality changes Emotional problems ENDOCRINE Feels weak Hot flashes Muscle weakness Deeper voice Bulging eyes (proptosis) HEM/LYMPH Bleeds easily Bruises easily Swollen glands Swollen glands in neck ALLERGY Allergic reaction Recurrent infection #7102 Revised 3/27/17
7 NAME REVIEW OF SYMPTOMS: Please check any of the following if you are currently experiencing symptoms: #7102 Revised 3/27/17
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