Patient History Form
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- Audra Townsend
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1 Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age Spouse Occupation: EDUCATION (circle highest level attended): Grade school College Graduate school Occupation Number of hours worked/average per week How did you hear about our clinic? Newspaper Yellow Pages Health fair Knowledge Night Radio Arthritis lecture Other Referred here by: (check one) Self Doctor Other health professional Name of person making referral: Do you have an orthopedic surgeon? Yes No If yes, name: Name of physician you will be seeing today Date symptoms began (approximate) Diagnosis: Indicate below any previous treatment for this problem (medications to be listed later): Physical therapy Surgery Please list the names of the other practitioners you have seen for this problem: RHEUMATOLOGIC (ARTHRITIS) HISTORY Yourself Arthritis (unknown) Osteoarthritis Gout Childhood arthritis Other arthritis conditions: Relative Name/Relationship Yourself Rheumatoid arthritis Ankylosing Spondylitis Osteoporosis Relative Name/Relationship Patient s Signature Date ACN Physician Initials Page 1
2 CURRENT MEDICATIONS Drug allergies: No Yes To what? Type of reaction: CURRENT MEDICATIONS (Please write down all your medications even if you bring them with you to your appointment. Include such items as over the counter pain medications i.e. Tylenol, ibuprofen, aspirin, along with any vitamins, laxatives, calcium and other supplements) Name of drug Dose (include strength & number of pills per day) How long have you taken this medication Please check: Helped? A lot Some Not at all Have you participated in any clinical trials for new medications? Yes No If yes list: PAST MEDICAL HISTORY Do you now or have you ever had: (check if yes ) Heart Problems Glaucoma Nervous Breakdown High blood pressure Colitis Sleep apnea Rheumatic fever Jaundice/Hepatitis Asthma Stroke Stomach ulcers Emphysema Tuberculosis Anemia Pneumonia (Hospitalized) Psoriasis Cancer Kidney Disease Diabetes HIV/AIDS Goiter Severe headaches Cataracts Seizure Disorder Natural or alternative therapies (chiropractic, magnets, massage, over-the-counter preparations, etc.) Patient s Name Date ACN Physician Initials Page 2
3 SOCIAL HISTORY Do you drink caffeinated beverages? Yes No Are you a: Nonsmoker Current smoker Every day Some days, but not every day How many cigarettes a day do you smoke? How soon after you wake up do you smoke your first cigarette? minutes Ready Thinking about it Not ready Former Smoker How long has it been since you last smoked? Do you smoke a pipe? Do you chew tobacco? Yes No If yes, please list: Did you have a drink containing alcohol in the past year? Yes No If Yes : How often did you have a drink containing alcohol in the past year? Never Monthly or less 2 to 4 times a month 2 to 3 times per week 4 or more times a week If Yes : How many drinks did you have on a typical day when you were drinking in the past year? If Yes : How often did you have six or more drinks on one occasion in the past year? Never Less than monthly Monthly Weekly Daily or almost daily Do you exercise regularly? Yes No Type of exercise Number of times per week Length of time in min. Hobbies How many hours of sleep do you get at night? Do you get enough sleep at night? Yes No Previous surgeries Do you wake up feeling rested? Yes No Type Year Reason Any previous fractures? No Yes Describe: No Yes Describe: No Yes Describe: _ FAMILY HISTORY IF LIVING IF DECEASED Age Health Age at death Cause Father Mother Number of brothers Number living Number deceased Number of sisters Number living Number deceased Number of sons Number living Number deceased List ages of each Number of daughters Number living Number deceased List ages of each Health of children: Do you know of any blood relative who has or had: (check and give relationship) - Alcoholism Colitis Psoriasis Thyroid disease Asthma Diabetes Rheumatic fever Tuberculosis Bleeding tendency Heart disease Cancer High blood pressure Stroke Patient s Name Date ACN Physician Initials Page 3
4 SYSTEMS REVIEW Mammogram No Yes Eye Exam No Yes No Yes Tuberculosis Test No Yes No Yes No Yes No Yes Tetanus (DTaP) No Yes Shingles Vaccination No Yes MONTH YEAR Constitutional Dermatology Eye Male Reproductive Psychology Night sweats Weight gain lb Loss of appetite Fever Weight loss lb Allergy Nasal polyps Sinus Drainage Allergy shots Seasonal Allergies Cardiovascular High blood pressure Raynaud s Chest pain Palpitations Leg edema Number of: Pregnancies Deliveries New hair loss bumps Allergy to sun Color change in cold Rash Psoriasis Hives Easy bruising Skin cancer Endocrinology New hormone pills New thyroid problem Excessive thirst Cold intolerance Heat intolerance Diabetes ENT Dry mouth Nosebleeds Hearing loss Mouth sores Sore throat Ringing in ears Sinus pain Dry eyes Red eyes Contacts Loss of vision Eye irritation or pain Eye mattering Blurring of vision Eye Inflammation Female Reproductive Vaginal discharge or bleeding Menstrual irregularity Risks for sexually HIV Contraception Menopause Hot flashes Gastroenterology Nausea Vomiting Abdominal pain Difficulty swallowing Diarrhea Constipation Blood in stool Hematology/ Lymph Anemia More infections than others Swollen glands Risk for sexually HIV Impotence Penile discharge Musculoskeletal Back or neck pain Leg cramps Bone density done elsewhere Fracture Neurology Muscle cramps Muscle weakness New weakness of arm or leg New headache Tingling numbness hands or feet Memory loss Ethnic origin Insomnia Feeling blue or depressed High stress level Difficulty with sleep Mental or physical abuse Worries or anxiety Respiratory Shortness of breath Coughing up blood Painful breathing Cough Urology Painful urinating Blood in urine Loss of urinary control Kidney stone Urination at night Patient s Name Date ACN Physician Initials Page 4
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