Internal Medicine Associates of Middle Georgia 97 Martin Luther King Jr. Drive Forsyth, Georgia 31029
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- Buck Sparks
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1 Internal Medicine Associates of Middle Georgia 97 Martin Luther King Jr. Drive Forsyth, Georgia Craig Caldwell, M.D. Jeremy T. Goodwin, M.D. Today s Date: 1. Name: 2. Address: Street Address: Apartment #: City/State: Zip: 3. Phone ( ) 4. What is your date of birth? / / 5. Sex: Male Female 6. Who filled out this form? *Relationship if other than patient? Phone ( ) 7. Who has been your previous primary doctor? Name: Address: Phone ( ) Fax ( ) 8. Do you plan to continue to be followed by this doctor? 1. No 2. Yes 3. Not sure
2 PAST MEDICAL HISTORY 9. Which medical conditions do you have or have you had in the past? (Check all that apply) I. EYE & EAR PROBLEMS a. Cataracts b. Glaucoma c. Macular degeneration of the eye d. Hearing loss/hearing aid e. Other, specify: II. HEART PROBLEMS a. Heart attack: Year b. Heart failure c. High blood pressure d. Irregular heartbeats (Arrhythmias) e. Other, specify: III. LUNG PROBLEMS a. Asthma b. Bronchitis c. Emphysema d. Other, specify: IV. BONE & JOINT PROBLEMS a. Arthritis b. Osteoporosis c. Fractured hip, wrist or spine (circle which one) d. Gout e. Other, specify: V. GLAND PROBLEMS a. Diabetes b. Thyroid overactive (high) c. Thyroid underactive (low) d. Other, specify: VI. KIDNEY & URINARY TRACT PROBLEMS a. Kidney disease b. Prostate disease c. Frequent bladder or kidney infections d. Urinary incontinence e. Other, specify: VII. GASTROINTESTINAL PROBLEMS a. Ulcers
3 b. Heartburn/Hiatal hernia c. Diverticulosis d. Liver disease/cirrhosis e. Hepatitis f. Polyps g. Gallbladder disease h. Other, specify: VIII. NERVOUS SYSTEM PROBLEMS a. Stroke b. Dementia or Alzheimer s Disease c. Parkinson s Disease d. Epilepsy or Seizures e. Other, specify: IX. OTHER HEALTH PROBLEMS a. Allergies, specify b. Anemia c. Hernia d. Thrombosis (blood clots) e. Cancer, of what f. Depression g. Sexual function problems, specify h. Other, specify 10. List Surgeries (Operations). Use back of page, if needed. DATE SURGERY (OPERATIONS)
4 11. List Other Hospitalizations. Use back of page, if needed. DATE REASON 12. Do you have any drug allergies? No YES. If YES, specify below NAME OF DRUG REACTION 13. List all medicines that you use. (Prescriptions, Non-Prescriptions, Natural Products) Current medications used regularly What strength? How do you use it? (How many? How many times a day?) Example: Tylenol 500mg 1 pill 3 times a day
5 14. With whom do you live? (check one) 1. Alone 2. Spouse or partner 3. Child or other family member 4. Others, not family 5. Other, specify: SOCIAL HISTORY 15. Which of the following best describes your residence? (check one) 1. Single-family house 2. Condo or apartment 3. Live with other in their home, condo or apartment 4. Retirement hotel 5. Board and care/residential care facility 6. Nursing Home 7. Other, specify: 16. Are you currently (check one) 1. Married 2. Divorced/Separated 3. Widowed 4. Single/Never married 5. Living with Significant Other 17. How many children do you have? Are you in regular contact with your children? Yes No 18. How much school did you complete? (check one) 1. Less than 6 th grade 2. Less than high school graduate 3. High school graduate 4. Some college 5. College graduate 6. More than college graduate 19. What has been your principal occupation? 20. Are you currently (check one) 1. Retired/Not working 2. Working part-time 3. Working full-time
6 21. Do you employ someone to provide care or help you in your home? If YES. How many hours a day and how many days a week is your paid helper available for you? hours a day and days a week Is this sufficient to meet your needs 22. Do you employ someone to provide care or help you in your home? If YES, approximately many hours a day and how many days a week is your family member or friend available for you? hours a day and days a week Is this sufficient to meet your needs 23. Who would you call if you were sick and needed help? 24. Do you provide care for a family member? 25. Do you drink alcohol, including beer and wine, or other alcohol (such as vodka, whiskey, gin)? 1. Daily 2. Almost daily (4 to 6 times a week) 3. 1 to 3 times a week 4. Less than 1 time a week 5. Never 26. If you drink alcohol, has anyone ever been concerned about your drinking? 27. Have you ever smoked cigarettes? If YES, Are you now smoking? a. no. If no, 1. How many years ago did you quit? 2. For how many years did you smoke? 3. How much did you smoke? pack per day b. yes. If yes, 1. How many years have you smoked? 2. How much do you smoke? pack per day
7 FAMILY HISTORY 28. Have any members of your family had any of the following conditions? Check all that apply 1. Dementia or Alzheimer s Disease 2. Cancer, of what? 3. Heart disease 4. Stroke 5. Diabetes 6. Depression 7. None of these PLANNING FOR FUTURE HEALTH CARE 29. Do you have a medical Durable Power o Attorney? (If yes, please bring a copy) 30. Do you have a living will? (If yes, please bring a copy)
8 31. We want to know if you need help with any of the following, and who helps you. Fill out for each task. TASK Feeding yourself Getting from bed to chair Getting to the toilet Getting dressed Bathing Using the telephone Taking your medicines Preparing meals Managing money/financial affairs/checkbook Doing laundry Doing house work Shopping for groceries Driving Doing handyman work Climbing a flight of stairs Getting to places beyond walking distance DON T NEED HELP NEED HELP IF YOU NEED HELP, WHO HELPS? (Name and Relationship)
9 32. To be certain that we ve covered everything, during the last three month, have you had any of the following symptoms or problems? (check all that apply) I. GENERAL PROBLEMS a. Weight Loss b. Weight gain c. Fevers d. Chills e. Sweats f. Cold or flu g. Change of appetite II. EYES a. Trouble seeing b. Eye pain c. Dry eyes III. EAR, NOSE, MOUTH, THROAT a. Trouble hearing b. Ear pain or itching c. Sinus problems d. Nose bleeds e. Sore throat f. Teeth problems g. Hoarseness h. Mouth sores i. Allergies IV. HEART PROBLEMS a. Chest pain or tightness b. Rapid or irregular heart beat c. Swelling of feet V. LUNG PROBLEMS a. Persistent cough b. Difficulty breathing or shortness of breath c. Coughing up blood d. Wheezing VI. DIGESTION PROBLEMS a. Difficulty swallowing b. Frequent indigestion or stomach ache, heartburn c. Frequent nausea or vomiting d. Change in bowel habits e. Black bowel movement or bleeding from rectum f. Frequent diarrhea g. Persistent constipation VII. BONE AND JOINT PROBLEMS a. Leg pain on walking
10 b. Back or neck pain c. Joint pain or stiffness d. Foot problems e. Falls VIII. BRAIN AND NERVOUS SYSTEM PROBLEMS a. Frequent headaches b. Frequent dizzy spells c. Passing out or fainting d. Falls e. Paralysis, leg or arm weakness f. Numbness or loss of feelings g. Serious problem with memory or difficulty thinking h. Tremor or shaking i. Problems with sleep IX. MOOD/SADNESS PROBLEMS a. Depression b. Anxiety X. GYNECOLOGY PROBLEMS a. Vaginal bleeding b. Breast lumps or discomfort c. Vaginal discharge XI. KIDNEY & URINARY TRACT PROBLEMS a. Urination at night (How many times) b. Frequent urination c. Painful urination d. Difficulty starting or stopping urination e. Loss of urine or getting wet. If yes, 6 or more times a year? XII. SKIN PROBLEMS a. Rash b. Sores c. Itching XIII. MISCELLANEOUS a. Excessive thirst b. Feel too hot or too cold c. Problems with sexual function If you have had none of the above problems listed in question 32 during the past 3 months, check here
11 HEALTH MAINTENANCE 33. Have you ever had an examination of your bowel with a scope (Circle which one: sigmoidoscopy or colonoscopy)? If YES, When did you have your most recent sigmoidoscopy or colonoscopy (Circle which one)? (year) 34. Have you had a hearing test within the last two years? Yes No 35. Have you had an eye exam within the past year? Yes No 36. In the past 12 months, have you had a test for blood in your stool (three cards at home)? 37. Have you seen a dentist in the last year? Yes No 38. Have you ever had the Pneumovax vaccine (a shot to prevent pneumonia)? 39. Have you ever had a tetanus shot? If YES, In what year did you have your last tetanus booster? (year) 40. Have you had a flu shot this season, (October-February)? 3. Not applicable (March-September) 41. Do you always wear a seatbelt when you ride in a car? 42. Do you currently participate in any regular activity to improve or maintain your physical fitness? (either on your own or in a formal class) If YES, check what you do currently. a. Walking b. Swimming c. Aerobics or exercise classes d. Dancing e. Jogging f. Bicycling or stationary bike g. Tennis h. Golf i. Bowling or bocce j. None of the above k. Other, specify
12 ANY PROBLEMS WITH FALLING? 43. Are you afraid of falling? No Yes 44. Have you had a fall in the past year? No (STOP. You do not need to fill out the rest of the page. Please turn to next page). Yes (Please continue with question 45 through 46) 45. Please tell us about your last 2 falls a. If you have had less than 2 falls, just tell us about the one you have had. b. To describe the circumstances of each fall, please tell us: what you were doing when you fell, what you think caused the fall, whether you experienced light-headedness or palpitations, how you landed (front/back/side), if there was loss of consciousness, and anything else you think is important. MOST RECENT FALL a. Date (as best you can): Month Year b. How did this fall happen (briefly describe circumstances): c. Did you need to see a doctor or other professional for treatment after this fall? No Yes PRIOR FALL Check here if not applicable (If you have only had one fall) a. Date (as best you can): Month Year b. How did this fall happen (briefly describe circumstances): c. Did you need to see a doctor or other professional for treatment after this fall? No Yes 46. Do you use a walking aid such as a cane or walker? No Yes Men proceed to question 47; women skip to question 49.
13 QUESTIONS FOR MEN ONLY (After completing question 48 please go to question 52) 47. Have you ever had a prostate exam (rectal exam)? If YES, when did you have your most recent prostate exam? (year) 48. Have you ever had a blood test to look for cancer of the prostate (PSA)? If YES, When did you have your most recent blood test to look for prostate cancer? (year)
14 QUESTIONS FOR WOMEN ONLY 49. Do you perform breast self-exam (BSE) once a month? 50. Have you ever had a mammogram? If YES, have you had a mammogram within the last year? a. no b. yes, month year 51. Have you had a hysterectomy (surgical removal of the uterus)? 1. YES (go to question 52) 2. NO If NO, have you ever had a Pap smear/pelvic examination? a. no (go to question 52) b. yes, month year
15 52. Have you ever had a bone density test or any test for osteoporosis? If YES, have you had a bone density test within the last 2 years? a. no b. yes, month year 53. Do you have any other health problems that you would like your doctor to know about before your visit?
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Patient Medical History Form
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Health History Questionnaire:
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
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