PATIENT HISTORY FORM
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- Jasper McBride
- 5 years ago
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1 Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician Date of Birth Soc. Security Number Street Address City/State/Zip Telephone Number(s) h (w) Please list all doctors you see: Doctor s Name Type of Doctor Reason for Seeing PRESENTING CIRCUMSTANCE DESCRIBE YOUR PRESENT MEDICAL SYMPTOMS (CHIEF COMPLAINT) Why are you here? HISTORY OF CHIEF COMPLAINT Problem Onset Location Radiation Quality Duration Timing Severity Aggravating Factors Relieving Factors Associated S/S hours days weeks months years PAST MEDICAL/SURGICAL HISTORY: DO YOU HAVE ANY ONGOING ILLNESSES OR PAST MEDICAL CONDITIONS SUCH AS: YES NO YES NO YES NO Asthma Thyroid Disease Angina/Chest Pain Bronchitis Under active (Hypo) Atrial Fibrillation Cancer (Where?) Overactive (Hyper) Heart Attack (MI) Peripheral Vascular Disease Pain in legs with activity Kidney Failure Hepatitis COPD/ Emphysema Stomach Ulcers Rheumatic Fever Stroke/CVA Seizures Scarlet Fever Diabetes Sleep Apnea Insulin Bleeding Problems High Blood Pressure Other High Cholesterol 1
2 ALLERGY DO YOU HAVE ANY ALLERGIES TO DRUGS OR FOOD: YES NO Allergy to: Reaction: MEDICATION List all Medications: Medication Name Dosage How often taken? Who Prescribed? Remember to bring all medications or a current list of medications with you at time of appointment, including dosage and frequency REVIEW OF SYSTEMS Instructions: Check yes or no to all of the following questions. If you answer yes, please explain on the right side of the page. General: YES NO Decreased exercise tolerance? Fatigue? Weight Change? Gain Loss How much? Period of time? Change in Appetite? Integumentary (Skin) Changes in moles? Rash? Itching? Changes in hair? Changes in nails? 2
3 Eyes: YES NO Do you wear glasses? Do you have blurred vision? Do you experience double vision? Do you have a history of cataracts? Glaucoma? Have you experienced visual field loss? Ears, Nose, and Throat: Do you have a hearing deficit? Dizziness with changing position? Chronic sinus problems? Do you have nose bleeds? Do you wear dentures? Hoarseness/Change in voice? Respiratory: Do you have a chronic cough? Productive? Have you coughed up blood? Do you experience shortness of breath? At rest? With Activity? Do you wheeze? Do you snore? Cardiovascular: Chest pain, pressure or tightness? at rest? with activity? Heart palpitations (racing)? Irregular heart beats? Short of breath lying flat? _How many pillows do you sleep on at night? Waking up panicky short of breath? Have you passed out? Swelling of feet or ankles? Pain in legs with walking? _Describe distance before pain develops Varicose veins? Nonhealing sores on legs or feet? History of blood clots or phlebitis? Gastrointestinal System: Frequent nausea? Frequent vomiting? Frequent diarrhea? Problems with constipation? Blood in Stool? Gallbladder problems? Liver Problems? Genitourinary: Do you have pain with urination? Blood in urine? Sense of urgency to urinate? Awaken frequently to urinate? History or bladder, kidney infection? History of kidney stones? Males: Prostate problems? Females: Post menopausal? 3
4 Musculoskeletal: YES NO Chronic back pain? Arthritis? History of Gout? History of blood clots in legs? History of vein ligation or stripping? Neurological: Temporary blurred vision/loss of vision? Temporary weakness and/or tingling involving an arm or leg? Severe Headaches? Migraine Headaches? Convulsions/Seizures? Psychiatric: Do you have a history of depression? Do you have chronic anxiety? Endocrine: High Cholesterol? Diabetes? Thryoid Problems? Hematological/Immunologic Chronic low blood count/anemia? Bleeding problems? Seasonal Allergies? Latex Allergy? ILLNESSES Problem / Date of onset Problem / Date of onset Medical Cardiac Infectious Trauma PROCEDURES Procedure / Date Procedure / Date Surgeries Cardiology Invasive Peripheral Vascular SOCIAL HISTORY AND LIFESTYLE: How many alcoholic beverages (beer, wine, or liquor) do you drink on an average day? Do you currently smoke Yes No What do you smoke? How much do you smoke? How long have you been smoking? If you quit smoking, when did you quit? How many packs per day did you smoke? How many years did you smoke before quitting? Are you on a special diet? Yes No What type of diet? How many cups of caffeinated beverages do you drink on an average day? Do you exercise on a regular basis? Do you have a history of drug dependency? Yes No If yes, specify Are you: Single Married Divorced Widowed 4
5 How many children do you have? What was the highest grade of formal education that you finished? Your occupation How many hours per week does it involve? Any heavy physical exertion while working? Yes No If yes, what types of things? FAMILY MEDICAL HISTORY Father Mother Brothers IF LIVING Age Health Age at death IF DECEASED Cause Sisters Any family history of cardiovascular disease, strokes, diabetes or cancer? Please explain: If you have a Durable Power of Attorney for Healthcare Needs, please provide us a copy. This will be included in your electronic medical record for Cypress Heart and allow us to comply with your healthcare directives. I have reviewed the above statements and to the best of my ability the information provided is a correct representation of my medical history. Signed Date 5
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Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
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.
Patient Medical History Form
Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear
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
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014
MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014 Name: Date of Birth: Today s Date: Where did you get healthcare before? May we request records? Y N (requires signed release)