Schodack Internal Medicine and Pediatrics Annual Physical-Female Please Fill out this form (or have your caregiver complete it) and discuss with your medical provider. Thank you! Please Mark the preferred phone number you want use to contact you. Patient Name: Date of Birth: Home Phone: Cell Phone: Work Phone: Address: City: State: Zip Emergency Contact: Relationship: Phone: Pharmacy: Phone Address: City: State: Zip Mail Order Pharmacy: Race: American Indian or Alaska Native Asian or Pacific Islander Black White Declined Unknown Ethnicity: Hispanic Non- Hispanic Declined Unknown Preferred Language: Current Concerns: Over-the-Counter Medication (Such as Aspirin) Strength Directions (Such as for headaches, when needed) Check if None Herbs, Vitamins, Minerals, Etc (Such as St. John's Wart) Strength Directions (Such as one tablet each day) Check if None Review of Systems: Do you currently have concerns with any of the following? Vision Problems Yes No Leg Swelling Yes No Muscle/Joint Pains Yes No Hearing Problems Yes No Leg pain with walking Yes No Memory Problems Yes No Headaches Yes No Abdominal Pain Yes No Depression Yes No Dizziness Yes No Heartburn Yes No Anxiety Yes No Chest Pain Yes No Difficulty Swallowing Yes No Urine Incontinence Yes No Palpitations/ Irregular pulse Yes No Constipation Yes No Frequent Urination Yes No Shortness of Breath Yes No Recurrent Diarrhea Yes No Blood in Urine Yes No Persistent Cough Yes No Blood in stool Yes No Snoring Yes No Unintentional Weight Loss/ Weight Gain Yes No Night Sweats/ Fever Yes No Loss of Sex Drive Yes No Skin Problems Yes No
Over the last two weeks, how often have you been bothered by the following feelings: Not at all Several days More than half the days Little interest or pleasure in doing things Feeling down, depressed, or hopeless Total for all the Columns: Nearly everyday If answered Zero (0) for above- STOP If answered 1 or greater please continue STOP Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself- or that you are a failure or have let yourself or family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could noticed. Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead, or of hurting yourself Add Columns + + Total for Columns =
Social History Are you working? Yes No Retired Occupation: Are you currently: Married Single Single but in a relationship Divorced Widowed Separated Do you have any children? Yes No Yes and are adult age How many? Please Check: Currently Every Day Smoker I smoke pack(s) per day for years Current some day smoker Former Smoker Quit Date pack(s) per day for years Never a Smoker Do you have or had have an exposure to secondhand smoke? Yes No If yes, from for how long? Do you drink alcohol? Never Rarely Occasionally 1-2/Day 3-4/Day >5/day Is there a family history of alcohol problems? Yes No If yes, which family member? Is there a family history of recreational drug use? Current use Yes No What drug(s)? Past use Yes No What drug(s)? Exercise: Or I exercise times per week. Type of Exercise I rarely Exercise Diet: I try to eat health or My diet needs improvement (please circle) Describe Diet ( How much fast food, avoid meat, fat, salt, sugar etc) I get Calcium from the following sources on a daily bases
Surgical History: Please list any surgeries that you have had and they year they were done No Change since last physical None 1) 2) 3) 4) 5) 6) Have you had a colonoscopy? Yes No If yes: when and with whom? Family History: Do you have any family members with the following (mainly parents, grandparents and siblings) Adopted, family history unknown No Change since last physical Who Heart attack/heart Disease Yes No Unsure High Blood Pressure Yes No Unsure High Cholesterol Yes No Unsure Aortic Aneurysm Yes No Unsure Brain Aneurysm Yes No Unsure Polycystic Kidneys Yes No Unsure Stroke Yes No Unsure Diabetes Yes No Unsure Thyroid Problems Yes No Unsure Osteoporosis Yes No Unsure Hip Fracture Yes No Unsure Spinal Fracture Yes No Unsure Depression Yes No Unsure Anxiety Yes No Unsure Glaucoma Yes No Unsure Hemochromatosis Yes No Unsure Breast Cancer Yes No Unsure Ovarian Cancer Yes No Unsure Colon Cancer Yes No Unsure Colon Polyps Yes No Unsure Melanoma Skin Cancer Yes No Unsure Lung Cancer Yes No Unsure Other Relevant Family History/Other Cancers: Have any family members died? If so, list age and reason Mother Father Sister (s) Brother(s) Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Advance Directives: If you have a Health Care Proxy and/or Advance Directives, please give a copy to office Are you interested in receiving information on Advance Care Planning Yes No
Do you have a caregiver? Yes No If yes: Name: Phone: Relationship: If Yes and you would like use to be able to speak with them about your care, please complete and sign a HIPAA form. Please list any Specialist that you see: Name of Doctor/Address/Phone Last Visit Podiatry (Foot Doctor) Ophthalmology (Eye Doctor) Cardiology Orthopedics Gastroenterology Nephrology (Kidney) Urology Psychiatry (Prescribes Meds) Psychology (Talk Therapy) Rheumatology Endocrinology Allergist Gynecology ENT (Ear/Nose/Throat) Pain Management Other Patient signature: Provider Signature: Date: