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Transcription:

Visit My Doctor Online at kp.org/mydoctor. Prepare for your visit This form will help you prepare for your upcoming visit with your doctor. You can complete it on your computer (Mac or PC) and e-mail it to your doctor ahead of time. Or, you may fill it out on the computer, print it, and bring it with you to your visit. Instructions for completing and saving this form vary depending on whether you use a Mac or a PC. Caution: When using a public computer (library, Internet cafe, etc.), saving your entries may make it possible for others to view your information. To avoid this, never save your personal information on a public computer. How to fill out the form Step 1 Step 2 PC users: Use your mouse to position your cursor over the field you would like to complete. Click inside the field and when your cursor appears, type your response to each question using your keyboard. Mac users: See Step 2. PC users: Please use your native browser (Internet Explorer): Click the Save button at the bottom of the form to create a copy of your completed form as a PDF document on your computer. In the dialog box that opens, you will be able to type in a file name for your form and select the folder where you want to store this file. Remember where you save this file. To print the form, select the Print button at the bottom of the form. Mac users: Please use your native browser (Safari): From the File menu select Save as to create a copy of your uncompleted form as a PDF document on your computer. In the dialog box that opens, you will be able to type in a file name for your form and select the folder where you want to store this file. Remember where you save this file. To fill out the form, open it with Acrobat Reader. Then, use your mouse to position your cursor over the field you would like to complete. Click inside the field and when your cursor appears, type your response to each question using your keyboard. Save your file. To print the form, select the Print dialog box from the File menu on Acrobat. Step 3 PC users, when you are ready to send this form, click the E-mail Form button, which will launch your browser. Then log in to your kp.org account. Mac users, please launch your browser and login to your kp.org account. Once your login is successful, create a message to your doctor. Attach the completed form by clicking on Browse in the Attach File section below your message. In the dialog box that opens on your screen, locate the form you saved on your computer in Step 2. Click on the file name to select it and click Open. This will select the form to be attached to your message. Click Send to send the message to your doctor. DONE! You can now close the browser. 2012, TPMG, Inc. All rights reserved.

Member Health History Name Today s Date Medical Record No Place of birth Your Occupation Marital Status Your Partner s Occupation If you have children, what are their ages? Who lives with you or do you live alone? What are your hobbies? PERSONAL MEDICAL HISTORY Allergy [Enter Asthma COPD/Emphysema Atrial fibrillation Heart murmur as an adult Heart disease/heart attack Congestive heart failure Rheumatic fever High cholesterol High blood pressure History of cancer or tumor [Enter Thyroid condition (hypo or hyper) [Enter Diabetes Osteoporosis Bone fractures Radiation treatments to the head/neck [Enter Glaucoma Acid reflux or heartburn Hepatitis [Enter Liver Cirrhosis Stomach or duodenal ulcer Irritable bowel disease Colon or bowel disease (including polyps) [Enter 2012 Kaiser Permanente All Rights Reserved DRAFT FORM No. PC-1 XXX FORM Page 1 of 5

PERSONAL MEDICAL HISTORY (continued) Kidney problem (including stones) Gynecologic problems (including fibroids or endometriosis) Prostate problems Migraine headaches Stroke Seizures/Epilepsy Arthritis Rheumatoid Arthritis or Lupus Gout Anemia Blood clots Blood transfusion before 1992 History of chicken pox Spleen removed History of pneumonia History of positive skin test for tuberculosis Alcohol/drug problem Anxiety or panic attacks Depression Bipolar disease Vegetarian diet PERSONAL SURGICAL HISTORY Abdominal surgery Appendix removed Back surgery Biopsy Breast surgery Coronary bypass Coronary stenting Gallbladder removal Heart surgery (other than bypass/stents) Page 2 of 5

PERSONAL SURGICAL HISTORY (continued) Hip surgery Hysterectomy (ovaries removed) Hysterectomy (ovaries left) Knee surgery Neck surgery Tubal ligation Spleen removed Other MEDICATIONS NAME DOSE DIRECTIONS DRUG ALLERGIES DRUG NAME REACTION Page 3 of 5

FAMILY HISTORY (check all that apply) NONE MOTHER FATHER SISTER BROTHER GRANDMOTHER GRANDFATHER Healthy Heart Disease Diabetes Drug Addiction Hypertension Hyperlipidemia Stroke Colon Cancer Colon Polyp Breast Cancer Prostate Cancer Alzheimer Disease Osteoporosis Aortic Aneurysm Alcohol Problem Anxiety Bleeding Disorder Clotting Disorder Depression Genetic Disorder Hemochromatosis Hepatitis Ovarian Cancer Panic Disorder Tuberculosis Thyroid Cancer Thyroid Disorder Page 4 of 5

PREVENTATIVE CARE (indicate dates, please bring documentation with you to your visit) Pneumonia vaccine Colonoscopy Tetanus vaccine Pap smear Zoster or chickenpox vaccine Mammogram Bone density scan OTHER HEALTH ISSUES Tobacco use Never Current smoker? Packs/day # Years Former smoker? # Years smoked Quit Date Other tobacco, including pipes, cigars, snuff, or chews Alcohol use Type of drink # of drinks /week Drug use Do you use marijuana or recreational drugs? Have you ever used needles to inject drugs? Sexual Activity Are you sexually active? Do you have sex with: Men Women Both Birth control method Do you have an Advance Directive for Health Care (ADHC)? Do you have a Durable Power of Attorney for medical decision-making? Do you have a Physician Order for Life Sustaining Therapy (POLST)? Page 5 of 5

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