Last Name: First Name: MI: 1. Have you recently had any major family changes: If yes, please explain:
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1 Adult Medical Questionnaire Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by the clinician during your consultations. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will help us formulate a treatment plan. Today s Date: Last Name: First Name: MI: Date of Birth: 1. Have you recently had any major family changes: If yes, please explain: 2. Past Medical and Surgical History: ILLNESSES WHEN COMMENTS Anemia Arthritis Asthma Bronchitis Cancer Chronic Fatigue Syndrome Crohn s Disease or Ulcerative Colitis Diabetes Emphysema Epilepsy, Convulsions, or Seizures Gallstones Gout Heart Attack/Angina 1
2 Heart Failure Hepatitis High Blood Fats (cholesterol, triglycerides) High Blood Pressure (hypertension) Irritable Bowel Kidney Stones Mononucleosis Pneumonia Rheumatic Fever Sinusitis Sleep Apnea Stroke Thyroid Disease Other (describe) INJURIES WHEN COMMENTS Back Injury Broken Bone (describe) Head Injury Neck Injury Other (describe) DIAGNOSTIC STUDIES WHEN COMMENTS Bone Density Pap Smear Mammogram Chest Xray Colonoscopy Cat Scan MRI Other (describe) 2
3 3. What medications are you taking now? Include non-prescription drugs: MEDICATION NAME DOSAGE Are you allergic to any medications: Yes If yes, please list: No 4. Please list all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate dosage in mg or IU and the form (e.g., calcium carbonate vs. calcium lactate) when possible: VITAMIN/MINERAL/SUPPLEMENT NAME DOSAGE 3
4 Health History Have you ever been hospitalized for illness? If so, please list when and why: Have you ever had the following procedures? If so, please list the dates: Coronary artery bypass surgery Revascularization procedures Angioplasty or stent Surgical History Please list all other operations with the dates when they occurred: Social History Tobacco use Cigarettes Never Date you quit smoking Current smoker (number per day) Other tobacco (Check all answers that apply): Pipe Cigar Chewing tobacco Number of years you ve used this tobacco Are you interested in quitting? Yes No Have you tried quitting in the past? Are you exposed to second hand smoke? Yes No For how long? Alcohol use Do you drink alcohol? Yes No If yes, how many drinks do you consume per week? Alcohol type Does your alcohol consumption have you or others concerned? Yes No Other concerns Caffeine intake Coffee cups/day Tea cups/day Soda per day Diet or Regular? Chocolate ounces per day Dark or Light? 4
5 Health History Weight Are you satisfied with your weight? Yes No What is your goal weight? When did you last weigh your goal weight? How long were you at that weight? Exercise Do you exercise regularly? Yes No What kind of exercise? How long do you exercise in minutes? How often? If you do not exercise, why not? Stress How would you classify your stress level at work? Low Medium High How would you classify your stress level at home? Low Medium High Do you often feel anxious, angry, irritated or rushed? No Yes How do you manage your stress? Diet/Nutrition How do you rate your diet? Please choose one: Good Fair Poor How many daily servings of the following do you typically have? Whole grains Fruits Vegetables Legumes How many times in one week do you consume the following items? Eggs Fish Chicken/Turkey Red meat Butter Margarine Other high fat dairy products Other low fat dairy products Fried foods High fat snacks What type of cooking oil do you use? Who prepares meals at home? How often do you eat out? 5
6 Health History Please describe in detail a typical day of eating and drinking: Breakfast: Lunch: Dinner: Snacks (include time of day): Beverages throughout the day: Review of Symptoms Please check any of the current problems you have on the list below: CONSTITUTIONAL: Fever/chills/sweats Unexplained weight loss/ gain Brittle nails Dry skin Change in skin texture Change in hair texture Inability to stand heat Inability to stand cold Change in energy/increased weakness Excessive thirst or urination CHECK: RESPIRATORY: Cough/Wheeze Snoring Sleep apnea/cpap 6
7 EYES: Change in vision (Explain) EAR/NOSE/THROAT/MOUTH: Difficulty hearing/ringing in your ears Hay fever/allergies Problems with teeth/gums CARDIOVASCULAR: Chest pain/discomfort Palpitations (irregular heartbeats) Swelling in feet or legs Varicose veins Pain in extremities with exercise SKIN: Acanthosis nigricans (dark lines around neck or under arms) Skin tags Flattening of nail beds GENITOURINARY: Unusual frequency of urination SEXUAL: Problems with erectile function GASTROINTESTINAL: Abdominal pain Blood in bowel movement Heartburn Nausea/vomiting Diarrhea/constipation Bloating NEUROLOGICAL: Headaches Light-headedness 7
8 Memory loss Loss of coordination Tingling, pain or numbness in hands or feet PSYCHIATRIC: Problems with sleep Depression Panic attacks Mania Anxiety Anger issues BLOOD/LYMPHATIC: Easy bruising/bleeding Unexplained lumps JOINTS/MUSCLES: Pains or aches in muscles Pain or aches in joints Arthritis Muscle fatigue Stiffness or limitation of movement Back and/or neck pain Any other symptoms? If so, please list them: 8
9 Health History Family History Please indicate the current status of your immediate family members. Include if each person is alive or deceased; the person s age now or at the time of death; if applicable, the cause of death; and any other relevant comments. Mother s mother Mother s father Father s mother Father s father Mother Father Sister Sister Sister Brother Brother Brother Daughter Daughter Daughter Son Son Son Please use this space to list any additional family members: 9
10 Please indicate with a check mark any family members who have had any of the following medical conditions: Medical Mom Dad Sister Brother Daughter Son Mom s Mom s Dad s Dad s Mom s Mom s Dad s mom dad mom dad sister brother sister condition Heart attack Stroke Diabetes-Type 2 (adult onset) Alcoholism Anemia Aortic Aneurysm Alzheimer s Arthritis Asthma Autoimmune disorder Bleeding problems Carotid artery disease Cancer Depression Diabetes-Type 1 (childhood onset) Dad s brother Other genetic disease High cholesterol (hyperlipidemia) High blood pressure (hypertension) Immunosuppressi ve disorders Kidney disease Osteoporosis Peripheral vascular disease Epilepsy (seizure disorder) Substance abuse Thyroid disorder Smoking Sleep apnea Thank you! 10
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Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
LAKES INTERNAL MEDICINE
LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma