Medical History. Instructions. My telephone number is: 1 Tools Medical History
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1 Medical History Instructions To do the best possible job with your heart failure, the doctor needs details about your history, including current and past medical problems, medications, health habits, and family history. For questions that ask about how you feel, please give your best answer yourself. The information about your past conditions may be gathered from both you and your family members. My name is: Date: My telephone number is: 1 Tools Medical History
2 First, describe the general problems you have with your health that bother you the most. Tell us the what, where, and when of your health problems. Are there things you can t do now that you wish you could? Please give your one best answer to the following questions: 1. In general, would you say your health is: Excellent Very Good Good Fair Poor 2. Compared to one year ago, how would you rate your health now? Much better Somewhat better About the same Somewhat worse Much worse 2 Tools Medical History
3 3. Does your health now limit you in the following activities: a. Vigorous activities, such as running, lifting heavy objects, or sports? b. Moderate activities, such as moving a table, pushing a vacuum, bowling, or golf? c. Lifting or carrying groceries? d. Climbing stairs? e. Bending, kneeling, or stooping? f. Walking several blocks? g. Walking one block? h. Bathing or dressing yourself? Code During the past 4 weeks, how much has your health interfered with your normal or desired level of work or social activities? Not at all Slightly Moderately Quite a bit Extremely Code Tools Medical History
4 Past Medical History Have you been affected by any of the following problems or conditions? If so, when was it first found? Condition When? Yes No High blood pressure!! Low blood pressure!! Heart attack!! Angina or coronary disease!! Heart failure!! Diabetes!! Kidney failure or trouble!! Thyroid disease!! Heart rhythm problems!! Pacemaker!! Heart murmur!! Anemia or low blood iron!! Passing out!! Falls!! Poor circulation!! High cholesterol!! Depression!! Arthritis!! Asthma or lung trouble!! Overweight!! 4 Tools Medical History
5 Current Medical History Please list the medical conditions currently affecting you or that you are currently receiving treatment for. Condition When Did It Begin? Psychiatric History Please list all psychiatric conditions or treatments you have had, with the approximate date of onset for each. Condition or Treatment Date 5 Tools Medical History
6 Operations Please list all operations with the date of operation. Operation Date Hospitalizations List the reason and month/year for hospitalizations in the past 10 years. Reason Month/Year 6 Tools Medical History
7 Family History Please indicate which family members have had any of the following medical conditions (give the relationship to you, not the relative s name). Condition Family Member(s) Heart disease/heart attacks Sudden death Stroke Poor circulation High cholesterol Diabetes Obesity Heart failure Health Habits If you ever smoked, how many packs per day and for how many years? If you no longer smoke, when did you quit? Have you ever used street drugs? No Yes Do you drink alcoholic beverages on most days? No Yes If yes, how many drinks per day, usually? (1 drink is 1 beer, 6 oz of wine, or 2 oz of hard liquor) Have you ever been a heavy drinker (6 drinks a day or more)? No Yes 7 Tools Medical History
8 Exercise History In the last few months, how much time each week did you spend in at least moderate exercise? < 15 min min min. > 120 min. Moderate exercise can be walking, bicycling, swimming, or heavy housework (vacuuming, cleaning). For example: 30 minutes per day, 3 days a week would be 90 minutes total for the week. What kind of exercise activities do you do? Salt Condition Yes No Do you add salt before you taste your food?!! Do you usually salt food at the table?!! Do you eat foods from the following list on most days (don t count low-salt versions)?!! Processed meats (luncheon meats, bacon, sausage) Fast food Cheeses Canned vegetables TV dinners or other prepared meals Chips or crackers Pastries or donuts 8 Tools Medical History
9 Medication History Please list all prescription medicines that you are currently taking. Name of Medication Strength and Times per Day Please list all over-the-counter medicines that you are currently taking at least once a week. Name of Medication Strength and Times per Day 9 Tools Medical History
10 Review of Symptoms Have you been bothered by any of the following problems in the past few months? Please describe any problems briefly, with approximate dates. If you need more room, write on the back of the sheet. Leave the line empty if the problem has not occurred. Problem Description, Date(s) Lack of energy Daytime sleepiness Dizziness Passing out Chest pain or discomfort Shortness of breath Cough Leg swelling Palpitations or skipped beats Sweating at night Trouble sleeping Depression or sadness Frequent or nighttime urination Confusion Sudden weight loss or gain Loss of appetite Joint pains or arthritis Problems having sex Trouble with the heat Prop up on pillows to sleep 10 Tools Medical History
Medical History. Instructions. My telephone number is: 1 Tools Medical History
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