MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014
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1 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) Allergies: Social History: Occupation: Who do you live with? Status: Single Married Separated Divorced Widowed Alcohol use: Never Quit Current use, # of drinks consumed per week (type: ) Tobacco use: Cigarettes/cigars/pipe: Never Quit date: Current use: packs/day for years Chewing tobacco: Never Quit date: Current use: # of cans/week Drug use: Never Quit date: Past use of: Current use: Exercise: None Regular exercise days per week. Type: Sexually active: Yes/No/Not Currently Male/Female Birth control method: Health Maintenance: Please give approximate date and result (normal or abnormal) if applicable, write NEVER if never done Date / Result Date / Result Physical Exam Colonoscopy PSA Tetanus booster Bone Density (DXA) Are there any other physicians involved in your care? (if so please list their names) Page 1
2 PAST MEDICAL HISTORY (Please circle if you have or have had any of the following) Comment Comment Comment Environmental Depression Heart Attack Allergies Anemia Diabetes Mellitus Nerve or Muscle Disease Anxiety Emphysema Osteoporosis Asthma GERD Seizures Blood Glaucoma Sickle Cell transfusion Anemia Cancer Heart Murmur Stroke Cataracts HIV/ AIDS Substance abuse Congestive High cholesterol Thyroid Disease heart failure Clotting High blood pressure Tuberculosis disorder COPD Kidney disease Ulcers Other (add): Meningitis PAST SURGICAL HISTORY (Please circle if you have or have had any of the following) Date Date Date Appendectomy Colon surgery Fracture Surgery Brain surgery Cosmetic surgery Joint replacement Angioplasty/stent Tonsils/Adenoids EGD (upper scope) Cardiac artery surgery Ear surgery Hernia repair Pacemaker/defibrillator Small intestine surg Valve surgery Eye surgery Spine surgery Vascular(vein/artery) Sinus surgery Prostate surgery/biopsy Gallbladder removal Uvulectomy (UPPP) Vasectomy Other (add): Patient Name: Date of birth: Page 2
3 PROVIDENCE MEDICAL GROUP - HAWKS PRAIRIE FAMILY MEDICINE Please complete accurately. Please also bring in your medications to your first visit in case your provider needs to see the prescription bottles. Medications Dosage Frequency Medication Allergies Patient Name: Date of Birth: Page 3
4 REVIEW OF SYSTEMS ***Circle the items in each category that presently cause you problems or discomfort*** ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ General Recent Weight Change Fever/chills Night sweats Fatigue Malaise/feeling ill Allergic/Immunologic Sneezing/runny nose Itchy/irritated eyes Nasal/sinus congestion Frequent colds/illness Recurrent pneumonia Recurrent sinus infections Integumentary (skin/breast) Rash or itching Change in skin color Change in hair or nails Varicose veins Breast Pain Breast Lump Breast discharge Skin ulcer Skin change/growth/lesion Skin infection Eyes Eye pain Eye redness Eye discharge Vision changes Blurred/double vision Ears/Nose/Throat/Mouth Hearing Loss or ringing Earaches or drainage Sinus problems Nose bleeds Sinus/face pain Bad Breath or bad taste Sore throat or voice change Swollen glands in neck Respiratory Cough Coughing/spitting blood Shortness of breath Wheezing Snoring Cardiovascular Chest pain Palpitation/irregular heartbeat Rapid heartbeat Shortness of breath Swelling of feet, ankles or hands Gastrointestinal Loss of appetite Nausea or vomiting Heartburn/reflux Abdominal pain Diarrhea Constipation Change in bowel movements Rectal bleeding/blood in stool Rectal/anal pain Bowel incontinence Genitourinary Frequent/urgent urination Burning/painful urination Blood in urine Difficulty with urination Incontinence/dribbling Sexual difficulty Painful periods Heavy periods Irregular periods Vaginal discharge Urethral discharge Musculoskeletal Joint Stiffness Joint pain Joint Swelling Muscle weakness Muscle pain/cramps Limb pain/injury Back pain/injury Neck pain/injury Cold extremities Difficulty walking Patient Name: Date of Birth: Patient Signature: Today s Date: Neurological Headaches Concussion Light headed/dizzy Fainting/collapse Seizures Numbness/tingling Weakness Tremors Paralysis Head Injury Endocrine Glandular/hormone problem Hot flashes/night sweats Excessive thirst/urination Heat or cold intolerance Dry skin Skin/nail changes Change in hat or glove size Hematological/Lymphatic Slow to heal after cuts Easy bleeding or bruising Vein problems Swollen glands Psychiatric Sadness/Grief Depression Panic/Anxiety Stress Hallucinations Sleep problems Substance abuse Alcohol abuse Suicidal thoughts Page 4
5 Page 5
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
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DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
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Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: MRN: Last Name: Date Of Birth: Contact Preference Email Telephone call- Work Telephone call - Home Email Please check one as your preferred
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden