MEDICAL HISTORY QUESTIONNAIRE
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- Dominick Rich
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1 929 SW Simpson Ave, Suite 300 Bend, OR Phone Fax MEDICAL HISTORY QUESTIOAIRE Date: Patient ame: DOB: Age: Please CIRCLE any of the conditions that you are experiencing TODAY. GEERAL/SYSTEMIC: Feeling tired General edema Chills ight sweats Recent weight loss Recent weight gain Difficulty falling asleep Snoring Daytime sleepiness EYES: Vision problems Blurry vision EAR/OSE/THROAT Ringing in the ears (tinnitus) Loss of hearing Sinus pressure osebleeds recurrent Mouth sores Bleeding gums Hoarseness Difficulty swallowing (dysphagia) ECK: Lump or swelling in the neck BREAST: Breast pain Breast lump ipple discharge CARDIOVASCULAR: Chest pain or discomfort Palpitations PULMOARY: Cough Coughing up blood (hemoptysis) Shortness of breath Wheezing GASTROITESTIAL: Abdominal pain ausea Vomiting Diarrhea Constipation Black or tarry stools (melena) GEITOURIARY Incomplete emptying of the bladder Pain during urination (dysuria) Urinary frequency Urinary loss of control Pelvic pain Vaginal discharge Bloody or dark urine EDOCRIE: Excessive thirst Temperature intolerance to heat Temperature intolerance to cold SKI: Skin rash Itching (pruritus) Skin lesion HEMATOLOGICAL: Easy bleeding MUSCULOSKELETAL: Diffuse joint pain (arthralgias) Back pain Muscle pain Muscle weakness EUROLOGOCAL: umbness (hypoesthesia) Tingling Dizziness Headache Vertigo Tremors Fainting (syncope) Seizure Feeling weak PSYCHOLOGICAL: Depression Anxiety Sleep disturbances Suicidal ideation Cry often Highly irritable Tense or under stress DEPRESSIO Depression recently Depression chronic SEXUAL Libido changes Unsatisfactory sexual interest Painful intercourse o Entry o Vagina o Deep o Other GYECOLOGY: Vaginal odor Vaginal itching or burning ALL OTHERS EGATIVE
2 AME DATE OF BIRTH AGE DATE OF SERVICE PCP REFERRED BY PHARMACY CC/HPI REVIEW OF SYSTEMS - SEE SEPARATE FORM MEDICAL HISTORY Yes o Yes o Blood clots (leg/lungs) [ ] [ ] Urinary tract infection [ ] [ ] Stroke [ ] [ ] High cholesterol [ ] [ ] Headaches / migraines [ ] [ ] Depression / anxiety [ ] [ ] High blood pressure [ ] [ ] Osteoporosis / osteopenia [ ] [ ] Diabetes [ ] [ ] Arthritis [ ] [ ] Cancer: (type) [ ] [ ] Asthma / lung disease [ ] [ ] Thyroid disease [ ] [ ] Breast disease [ ] [ ] Heart disease / murmur [ ] [ ] Blood disorders / anemia [ ] [ ] Jaundice / hepatitis [ ] [ ] Transfusion [ ] [ ] Digestive / bowel disorders [ ] [ ] eurologic disorder [ ] [ ] Gallbladder disease [ ] [ ] Skin disease [ ] [ ] Kidney disease [ ] [ ] Other [ ] [ ] SURGICAL HISTORY Year Procedure Year Procedure GYECOLOGIC HISTORY Yes o Any abnormal PAP smear? [ ] [ ] Treatment for cervical dysplasia? [ ] [ ] DES exposure? [ ] [ ] Sexually transmitted infections? [ ] [ ] Circle: chlamydia; gonorrhea; syphilis; herpes; HPV: genital warts; HIV; Hepatitis B; trichamonas MEOPAUSAL MESTRUATIG (if menopausal, omit) first period? First day of last period? last period? first period? Do you take hormones? How often do you bleed? Have you used hormones in the past? How many days do you flow? Do you have vaginal bleeding? Do you spot between periods? Are periods painful? PREGACY HISTORY Are periods heavy? umber of pregnancies Do you use any kind of birth control? umber of living children Type of birth control? umber of term deliveries Reviewed by Date Done: JB ALM MA Date
3 PREGACY HISTORY umber of pre-term deliveries (more than 3 weeks early) umber of adopted children umber of miscarriages / abortions umber of tubal pregnancies (ectopic) LIFE STYLE Do you exercise? Yes [ ] o [ ] Frequency? Type? Do you take a calcium supplement? Yes [ ] o [ ] How much? Do you take a vitamin D supplement? Yes [ ] o [ ] How much? Do you drink alcohol? Yes [ ] o [ ] How much? Do you smoke? Yes [ ] o [ ] How much? Have you ever smoked? Yes [ ] o [ ] How much? Have you ever used IV drugs? Yes [ ] o [ ] Are you currently in a sexual relationship? Yes [ ] o [ ] umber of sexual partners ever? Have you changed sexual partners in the last 5 years? Yes [ ] o [ ] Is your sexual partner male or female? Male [ ] Female [ ] SOCIAL HISTORY Yes o Do you work outside the home? [ ] [ ] Is anyone hurting you? [ ] [ ] Has anyone ever sexually violated you? [ ] [ ] HEALTH MAITEACE Last mammogram? Year Tetanus / pertussis Year Last PAP smear? Year Shingles Year Last cholesterol test? Year Pneumovax Year Colorectal cancer screening? (if >50 years old) Year Meningococcal Year Stool blood test? Year Hepatitis B Colonoscopy? Year Year: #1 #2 #3 Bone density study? Year HPV Pneumococcal vaccine? Year Year: #1 #2 #3 Tetanus booster? Year FAMILY HISTORY Yes o Type (organ)? Who? Cancer? [ ] [ ] [ ] [ ] [ ] [ ] Who? Heart disease? [ ] [ ] Diabetes? [ ] [ ] High blood pressure? [ ] [ ] Osteoporosis [ ] [ ] Stroke? [ ] [ ] Blood clots in legs / lungs? [ ] [ ] Thyroid disease? [ ] [ ] Drug / alcohol abuse? [ ] [ ] Mental disorders? [ ] [ ] Other? [ ] [ ] [ ] [ ] MEDS / ALLERGIES - see problem list
4 Cancer History Questionnaire ame: Date of Birth: Gender: Health Care Provider: Instructions: This is a screening tool for cancers that run in families. Please mark (Y) for those that apply to YOU and/or YOUR FAMILY. ext to each statement, please list the relationship(s) to you and age of diagnosis for each cancer in your family. You and the following close blood relatives should be considered: You, Parents, Brothers, Sisters, Sons, Daughters, Grandparents, Grandchildren, Aunts, Uncles, ephews, ieces, Half-Siblings, First-Cousins, Great-Grandparents and Great-Grandchildren You and your family s Cancer History (Please be as thorough and accurate as possible) Y Y Y Y Y Y Y Y Y CACER YOU Parents/Siblings/ Children Example: Breast Cancer Aunt Cousin Breast cancer (Female or Male) Ovarian cancer (Peritoneal/Fallopian tube) Endometrial ( Uterine ) cancer Colon/rectal cancer 10 or more Lifetime Colon/Rectal Polyps (Specify #) Pancreatic cancer Prostate cancer Other Cancer(s) (Specify cancer type) Relatives Maternal Side Are you of Ashkenazi Jewish descent? (circle one) YES O Are you concerned about your personal and/or family history of cancer? (circle one) YES O Have your or anyone in your family had genetic testing for a hereditary cancer syndrome? (Please explain/include a copy of result if possible) If Yes, Who? What gene(s)? What was the result? Relatives Paternal Side Grandmother 53 BREAST CACER RISK MODEL IFORMATIO HEREDITARY CACER RED FLAGS (COMPLETE WITH YOUR HEALTH CARE PROVIDER) Your current height (ft/in) Your current weight (lbs) Your menopausal status: Pre-menopausal Peri-menopausal (time before menopause marked by irregular cycles) Post-menopausal: onset (Permanent cessation of period for 12 months or longer) Your age at time of first menstrual period Your age at time of first live birth Did you ever use Hormone Replacement Therapy? Yes o If yes, type: Combined Estrogen only Progesterone only unknown If yes, are you a: Current user: How many years ago did you start? Intend to use for more years Past user: How many years ago did you stop using? o Have you ever had a breast biopsy? Yes If yes, do you know your diagnosis? umber of daughters umber of sisters umber of maternal aunts (mother s sisters) umber of paternal aunts (father s sisters) Personal and/or family history of any one of the following (check all that apply) MULTIPLE: A combination of cancers on the same side of the family: 2 or more: breast / ovarian / prostate / pancreatic cancer 2 or more: colon/rectal / endometrial / ovarian / gastric / pancreatic / other (i.e., ureter/renal pelvis, biliary tract, small bowel, brain, sebaceous adenomas) 2 or more: melanoma / pancreatic YOUG: Any 1 of the following at age 50 or younger: Breast cancer Colon/rectal cancer Endometrial cancer RARE: Any 1 of these rare presentations at any age: Ovarian cancer (Peritoneal/Fallopian tube) Breast: Male breast cancer or Triple negative breast cancer (ER-, PR-, HER2- Pathology) Colon/rectal cancer with abnormal MSI/IHC, or MSI high associated histology Endometrial cancer with abnormal MSI/IHC 10 or more colon/rectal polyps* Certain ancestries such as Ashkenazi Jewish, may have greater risk for hereditary cancer syndromes
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![Placer Private Physicians: Patient Health Questionnaire [2]](/thumbs/87/96006031.jpg "Placer Private Physicians: Patient Health Questionnaire [2]")
Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
OB/GYN COMPREHENSIVE PATIENT INTAKE HISTORY
FOR OFFICE USE ONLY NEW PATIENT ESTABLISHED PATIENT CONSULTATION REPORT SENT: / / OB/GYN COMPREHENSIVE PATIENT INTAKE HISTORY PATIENT NAME: AGE: BIRTHDATE / / DATE: / / RACE: CAUCASIAN AFRICAN-AMERICAN
New Patient Information Form
New Patient Information Form Patient Label Dear Patient: Please take a few minutes to complete this form. Your answers will help the doctors and staff plan and provide your care. If you are unsure of any
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
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
NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name
NEW PATIENT FORM Please print in ink and fill in all blanks Please fill out front and back Patient s Full Name Date of Birth Age Sex Social Security Number Referring Doctor or Family Physician Phone #
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
Patient First Name Patient Middle Initial Patient Last Name. Primary Care Physician Primary Care Physician Phone Pharmacy Name
NP Hagans Walk-In Clinic * 9135 Piscataway Rd. # 320 Clinton, MD 20735 * (240)-412-5093 (Office) Patient Information Patient First Patient Middle Initial Patient Last Sex Marital Status Date of Birth Social
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 registration
Patient registration Name: DOB: Sex: Date: Who referred you to our office? Other Physicians you see: Occupation: Place of Employment: Marital Status (Please Circle): Single Married Separated Divorced Widowed
/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
Health History. Tests and Procedures: Test: Date: Location: Provider: Abnormal: Results/Notes: Monthly self breast exam. Last mammogram (female)
Comprehensive Cancer Center A Cancer Center Designated by the National Cancer Institute Please answer the following questions and bring this form to your first appointment at Rutgers Cancer Institute of
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please