Wheaton Franciscan Healthcare

Transcription

1 Today s Date Wheaton Franciscan Healthcare PATIENT AND FAMILY MEDICAL HISTORY Patient s Name: Marital Status: r Married r Single r Divorced r Widowed r Other Date of Birth: Gender: r Male r Female Religion: Covenant Clinic collects this demographic information to ensure high quality health care is provided to all of our patients. Thank you. Race Ethnicity Spoken Language Black Hispanic English White Non-Hispanic Other: American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander Multiracial: r Alaskan Native/American Indian r Asian r Black/African American r Hawaiian/ Pacific Islander r White/Caucasian r Unknown r Declined Do you have a Living Will? If no, would you like information? Do you have an Advance Directive? If no, would you like information? Do you have a Power of Attorney? If no, would you like information? PATIENT MEDICAL HISTORY Please answer each question. Allergies List: Anemia Date: Anxiety Date: Arthritis Date: Asthma Blood Infusion Date: Cancer Date: Type: Cataracts Date: Congenital Heart Failure (CHF) Date: Clotting Disorder Date: COPD Date: Coronary Artery Disease Date: Depression Date: Diabetes Mellitus Date: r Type 1 r Type 2 r Gestational Emphysema Date: GERD Date: Glaucoma Date: Heart Murmur Date: HIV/AIDS Date: Hypertension Date: Page 1 of 5

2 PATIENT MEDICAL HISTORY...continued Hyperthyroidism Date: Hypothyroidism Date: Hyperlipidemia Date: Kidney Disease Date: Meningitis Date: Myocardial Infarction Date: Nerve/Muscle Disease Date: Osteoporosis Date: Seizures Date: Sickle Cell Anemeia Date: Stroke Date: Thyroid Disease Date: r Hyper r Hypo r Goitre Tuberculosis Date: Ulcers Date: Other Medical History: MENTAL HEALTH Attention Deficit Disorder Date: Bipolar Disorder Date: Depression Date: Mental Disorder Date: Schizophrenia Date: PATIENT SURGICAL HISTORY Appendectomy Date: Brain Surgery Date: Breast Surgery Date: C-Section Date: CABG Date: Cholecystectomy Date: Colon Surgery Date: Colonoscopy Date: Cosmetic Surgery Date: Eye Surgery Date: Fracture Surgery Date: Location: Hernia Repair Date: Hysterectomy Date: Joint Replacement Date: Prostate Surgery Date: Small Intestine Surgery Date: Spine Surgery Date: Tonsillectomy Date: Tubal Ligation Date: Valve Replacement Date: Vasectomy Date: Other Medical History: Page 2 of 5

3 Please mark for each answer and list the family member(s), where applicable. * Family includes children, parents, grandparents and siblings. Please identify which side of the family maternal or paternal. FAMILY HISTORY Alcohol Abuse Arthritis Asthma Birth Defects Cancer COPD Depressions Diabetes Drug Abuse Early Death Hearing Loss Heart Disease Hyperlipidemia Hypertension Kidney Disease Learning Disability Mental Illness Mental Retardation Miscarriages Stroke Vision Loss Anesthesia Problems Broken Bones Dislocations Are you adopted? Family History: r Known r Unknown FALL PREVENTION Have you fallen in the last 6 months? Page 3 of 5

4 ALCOHOL USE Alcohol Use: r Never Drinks/Week: # Glasses of Wine # Cans of Beer # Shots of Liquor # Drinks containing 0.5 ounces of alcohol Alcoholic Drinks per week: Do you have a past of heavy use of alcohol? Have you ever been in an alcohol treatment program? Sobriety Date: SEXUAL ACTIVITY Are you: r Sexually Active r Not Sexually Active Birth Control Use: Type(s): Last Menstrual Date: Are you pregnant or planning on becoming pregnant? - If you are pregnant, what is your due date: ILLEGAL DRUG USE r No reported history of drug use Place place a check mark for each drug listed you have used in the past or currently using. Drug Type(s): Past Use Current Use Past Use Current Use Amphetamines (speed) MDMA (ectasy) Amyl Nitrate (rush) Methaqualone (quaaludes) Anabolic Steroids Methylphenidate (ritalin) Barbiturates Morphine Benzodiazepines (Ativan, Xanax, etc.) Nitrous Oxide (laughing gas) Cocaine Opiates Fentanyl Oxycodone Flunitrazepam (roofies) PCP GHB Psilocybin (mushrooms) Hashish Solvent Inhalants (glue, lighter fluid, Heroin Hydrocodone Hydromorphone (dilaudid) Ketamine LSD hair spray, air freshner, spray paint, etc.) Other(s): Usage amount per week: Have you used needles to inject drugs: Have you ever been in a drug treatment program? Do you currently have a pain management contract? Page 4 of 5

5 TOBACCO USE Smoking: r Never Smoked r Former Smoker Quit Date: r Current Smoker Type: r Cigarette r Cigar r Pipe How many years have you smoked? Amount per day: r Less than Half a Pack r Half a Pack r 1 Pack r 2 Packs r 3 Packs Are you interested in quitting: Smokeless: r Former Smokeless User Quit Date: r Current Smokeless User Type: r Chew r Snuff r Powder Amount per day: Are you interested in quitting: SCREENINGS Abuse Assessment: Are you currently or have you ever been physically shoved, hit, kicked, or mentally controlled or made to feel afraid? r Decline Page 5 of 5