Patient Information: Date: Last Name: Street Address: City: SS #: First Name: Sex: M F Birthdate: Contact Information:

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1 Welcome to PHC Family Medicine! We know you have a choice and appreciate your choosing us to provide care to your family. Dr. Frankhouser will be asking about your concerns today, but so that we can learn more about you, please complete this questionnaire. Some questions may be a little startling, but please understand that they address current national health concerns and efforts and allow us to provide you with the best care possible. Please return the completed forms to a staff member. Thank you again for choosing PHC Family Medicine to keep you well! Patient Information: Date: Last Name: Street Address: City: SS #: First Name: State: Zipcode: Sex: M F Birthdate: Contact Information: Home Phone: ( ) Cell Phone:( ) Emergency Contact Information: Name: Relationship: Home Phone: ( ) Cell Phone:( ) MI: Other Physicians and Providers of Care Name and Specialty/Provider Type Type of Care Date Discontinued Please list name, dose, and frequency for the following: Prescription MEDICATIONS VITAMINS/HERBS/MINERALS OTC MEDICATIONS Please list any ALLERGIES and reactions below:

2 Health History Do you have a personal history of: AIDS/HIV Epilepsy Osteoporosis Anemia Glaucoma Pacemaker Anorexia Goiter Psychiatric Care Anxiety Gout Rheumatoid Arthritis Arthritis Headache Rheumatic Fever Asthma Heart Disease Sexually Transmitted Disease Bleeding Disorder Hepatitis Stroke Cancer High Blood Pressure Suicide Attempt Type: High Cholesterol Thyroid Problems COPD Kidney Disease Tuberculosis Depression Liver Disease Other: Diabetes Multiple Sclerosis Other: Have you had any of the following surgeries: Appendectomy (Date: / / ) Joint Replacement Tonsillectomy (Date: / / ) Joint: Cholecystectomy (Gallbladder) (Date: / / ) Date: / / Adenoidectomy (Date: / / ) Oopherectomy (Date: / / ) Hysterectomy (Date: / / ) Prostatectomy (Date: / / ) Other: Date: / / Family History (Use a to indicate positive history) Condition Family Member Condition Family Member Alcoholism Anxiety Asthma Breast Cancer Colon Cancer Depression Diabetes Heart Disease Heart Attack High Blood Pressure High Cholesterol Lung Cancer Migraine Osteoporosis Ovarian Cancer Prostate Cancer Skin Cancer Stroke Thyroid Disease Uterine Cancer Other Cancer Other Condition

3 Social History 1. When was your last comprehensive health examination (bloodwork, EKG, etc.)? Date: / / 2. Do you wear glasses or contacts? Yes No 3. When was your last eye exam? Date: / / Never Unknown 4. When was your last dental exam? Date: / / Never Unknown 5. When was your last colonoscopy? Date: / / Never Unknown 6. When was your last DEXA scan? Date: / / Never Unknown 7. Have you been screened for an aortic aneurysm? Date: / / Never Unknown 8. When was your last Tetanus shot? Date: / / Never Unknown 9. When was your last Pneumonia shot? Date: / / Never Unknown 10. If you are a female, please answer the following questions: Last breast exam by your physician? Date: / / Never Unknown Last mammogram? Date: / / Normal Abnormal Never Unknown Last PAP smear? Date: / / Normal Abnormal Never Unknown Last HPV testing? Date: / / Normal Abnormal Never Unknown Are you pregnant? Yes No Due Date: 11. Are you sexually active? Yes No If YES please select all that apply: Single Male Partner Multiple Male Partners Sex Worker Single Female Partner Multiple Female Partners Safe Sex 12. Method of Contraception - Please Choose Below OR Select No Contraception Oral Contraceptives IUD Contraceptive Patches Condoms Tubal Occlusion Postcoital Contraception Diaphragm Tubal Ligation Intravaginal Ring Withdrawal Vasectomy (Partner) Timing Abstinence DepoProvera Natural Family Planning Hysterectomy Hormone Implants Spermicides 13. Marital Status: Single Married Widowed Separated Divorced 14. Education: <8th Grade Some High School High School/GED College Advanced Degree

4 Health Habits - Please complete below: Tobacco Current Type: Frequency: 2nd Hand Never Prior Use Quit Date: Alcohol Never Occasional Daily If you consume alcohol occasionally or daily, please answer the following questions: Have you ever felt you should cut down on your drinking? Yes No Have people annoyed you by criticizing your drinking? Yes No Have you ever felt bad or guilty about your drinking? Yes No Have you ever had a drink first thing in the morning to steady your Yes No nerves or get rid of a hangover? History of Alcohol Use (Please Describe): Drug Use Never Occasional Daily Prior Use Quit Date: History of Drug Use (Please Describe): Vaping Current Never Prior Use Quit Date: Caffeine Current Type: Frequency: Do you have a living will or advance directive? Yes No Is there a gun in your home? Yes No If you answered yes, is it locked away and unloaded? Yes No Do you wear your seatbelt? Yes No Do you exercise? Yes No Frequency None Infrequently Daily Minutes/Day Times/Week Hours/Week Type Walking Running Biking Swimming Yoga Strength Training Other:

5 Please tell us what you would like to discuss with the doctor: Review of Systems (Please any symptoms you are CURRENTLY experiencing) Please check this box if all symptoms are negative. General GI Neurological Fever Abdominal Pain Headache Chills Constipation Confusion Fatigue Nausea Numbness Weight Change Diarrhea Dizziness HEENT Vomiting Fainting Red Eyes Blood in Stools Tingling Difficulty Seeing GU Difficulty Walking Hearing Change Pain on Urination Psych Nasal Discharge Leaking of Urine Suicidal Thoughts Sore Throat Pelvic Pain Sleep Disturbances Hoarseness Vaginal Discharge Anxiety Cardiovascular Musculoskeletal Depression Chest Pain Joint Pain Lymph/Heme Palpitations Muscle Weakness Swollen Glands Lower Leg Swelling Skin Easy Bleeding Respiratory Rash Easy Bruising Shortness of Breath Wheezing Cough Depression Screening: Wound Over the past 2 weeks, have you felt down, depressed or hopeless? Yes No Over the past 2 weeks, have you felt little interest or pleasure in doing things? Yes No