Personal Health Risk Appraisal
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- Emily Cox
- 5 years ago
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1 Today s Date: Premier Arthritis and Osteoporosis Center 722 North Fairfield Road Beavercreek, OH Phone (937) Fax (937) Personal Health Risk Appraisal Last Name: First Name: MI: Address: (Street Address) (City) (State) (Zip) Birthdate: Age: Marital/Partner Status: Home Phone: Work Phone: Cell Phone: Employer: Job Title: Do you have children? Yes No If so, how many? Ages? Do they live with you? Yes No Personal Health History Check illnesses that you are experiencing, either currently or in the past. Give details below: Illness Yes Illness Yes Illness Yes Addictions Alcoholism Allergies Arthritis Asthma/Hay Fever Anemia/Blood Disorder Blood Transfusion Broken Bones Bowel Disease Chicken Pox Constipation Diarrhea Cancer (Describe type) Cataracts Chronic Bronchitis/Emphysema Chronic Cough Chest Pain Depression Diabetes Deafness/Hearing Difficulty Drug Abuse Epilepsy/Seizures Ear/Nose/Throat Problems Fainting/Dizziness Glaucoma Gall Bladder Disease Glasses/Contact Lens High Blood Pressure High Blood Cholesterol Hemorrhoids Head Injury Hernia Heart Disease Jaundice Joint Problems Kidney/Bladder Disease Mumps Measles Nervous/Emotional Disorders Rheumatic Fever Sexually Transmitted Skin Diseases Diseases Stroke Tuberculosis (TB) Ulcer/Stomach Trouble Venereal Disease (warts, herpes, HIV, syphilis) Other (Describe): (over) Page 1 of 1
2 Please complete to describe your symptoms. If you are unsure about a symptom, please check Not sure. GENERAL: Tiredness? Fever? If you had a fever about how many days? How high did the fever go? Days Temp Have you decreased your activities due to physical problems? Hospitalized since last visit? Days absent from work or school due to rheumatic disease? Weight gain/loss? Yes No Not sure FEMALES ONLY If menstrual cycles started, are they regular? Are you pregnant? Date of first day of last menstrual period? Genital/vaginal sores? Vaginal dryness? MALES ONLY Discharge from penis? Rash or sores on penis? Yes No Not sure HEAD, EYES, EARS, NOSE, MOUTH AND THROAT Headache? Loss of hair? Dry eyes or mouth? Red or painful eyes? Mouth sores Sore threat? CHEST, LUNGS, AND HEART Chest pain? Shortness of breath? GASTROINTESTINAL SYSTEM Loss of appetite? Weight loss? Difficulty swallowing or feeling of food getting stuck? Heartburn, acid reflux? Nausea or vomiting? Pain or cramps in abdomen? Loose or frequent bowel movements? Vomiting blood or black or tarry stools (not from iron)? Last colonoscopy? GENITOURINARY SYSTEM Blood in urine? Burning on urination? BONES, MUSCLES & JOINTS Muscle pain? Neck pain? Joint pain? Which joints? Joint swelling? Which joints? Night pain? Weakness of muscles? If you are stiff in the morning, about how long does it usually last? minutes NERVOUS SYSTEM Difficulty sleeping? Nervousness? Trouble thinking or remembering? Change in personality? Depression? Seizures or convulsions? Numbness or tingling? SKIN Easy bruising? Skin tightening? Rash over cheeks? White, blue and red skin color change in fingers on exposure to cold or stress? Sun sensitivity (unusual skin reaction, not sunburn)? Other rash? PAIN 1. On a scale of 1-10, how much pain has the illness caused in the last week (Circle one)? No pain Severe pain 2. Duration of pain (Circle one): Constant Intermittent Other 3. Type of pain (Circle one): Sharp Throbbing Aching Dull Burning Other Unable to Describe Page 2 of 2
3 Family Health History Check any disease which affected a member of your immediate family (parent, sibling, grandparent). Specify which relative has or had the disease: Illness Yes Which Relative? Alcoholism Nervous/Mental Disorder Obesity Heart Disease Stroke Osteoporosis Breast Cancer Lung Cancer Kidney Disease Anemia/Blood Disorder Colon Polyps Illness Yes Which Relative? Drug Abuse High Blood Pressure Lung Disease Diabetes Seizures Colon Cancer Ovarian Cancer Other Cancer Liver Disease Prostate Cancer Other Current Symptoms/Health Concerns Please describe any additional symptoms or concerns that you would like to discuss with your physician: Past Surgeries/Hospitalizations List the dates and the reasons for hospitalization and/or type of surgery: Pregnancies List number of pregnancies, vaginal or c-section, and any complications. Allergies List all substances to which you have been told you are allergic. Include medications, dyes, environmental products, etc. What was the reaction to the allergen?: (Over) Page 3 of 3
4 Current Medications List all current medications. Include over-the-counter meds and herbal remedies: Name of Medication Dose Time of day taken Personal Habits What is your highest level of education (high school, college, trade school) If working, do you work full-time or part-time? FT PT Do you currently smoke tobacco? Yes No If so, how many cigarettes do you smoke each day? If you smoked cigarettes in the past, when did you stop? Describe any other tobacco use: How many alcoholic beverages do you drink per day? Per week? Describe any drug use (not medications): Are you sexually active? If yes, men, women, or both? Do you practice safe sex? Yes No Wellness Complete the following statement: Overall, I would rate my health as (check one box): Excellent Very Good Good Fair Poor Page 4 of 4
5 How many days per week do you engage in some form of aerobic exercise of at least 20 minutes duration (walking, biking, swimming, exercise class, other sports)? What other types of physical activity do you engage in on a regular basis? If you are unable to be active on a regular basis, please describe the reasons why: Are you on a special diet? Yes No How many caffeinated beverages do you drink per day? How much has your weight changed in the past year? Gain/Loss lbs. Preventative Medical Care Check the boxes that apply to you: Yes No If yes, when/where? Physical exam in past 5 years Cholesterol check in the past 2-5 years Blood pressure check in the past year Dental exam in the past year Vision exam in past 3 years Colon cancer screening in past 1-3 years (over age 50) Women: Pap smear exam in past 1-3 years Mammogram in past 1-2 years Breast self-exam monthly Bone density exam in past 2 years Men: Testicular self-exam monthly PSA (blood test for prostate cancer) in past 1-2 years Immunizations: Pneumonia vaccine Flu shot - yearly Hepatitis A vaccine (2 shots) Hepatitis B vaccine (3 shots) Thank you for working with us to improve your health. Signature of person completing form: Relationship to patient: Physician signature Date (Revised 09/2007) Page 5 of 5
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Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.
Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
New Patient Medical History Form
New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring
Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program
Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program If you are reading this you have been fortunate enough to qualify for a consultation with Dr. Zammito at
Naturopathic Intake Form PERSONAL MEDICAL HISTORY
List any surgeries, hospitalizations, imaging (CT, MRI, EEG, EKG, etc.) Date MM/YY ALLERGIES Do you have any allergies to medications? [ ] Yes [ ] No If yes, list medication and reaction Do you have any