New Patient History. Patient Name: Date of Birth: Reason for Today s Visit: Today s Date: Who is your Primary Care Physician (PCP)?

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Transcription:

ew Patient History Patient ame: Date of Birth: Reason for Today s Visit: Today s Date: Who is your Primary Care Physician (PCP)? Review of Systems Please circle any concerning symptoms you are currently experiencing: Constitutional: Dermatology: Endocrinology: CV/Respiratory: eurology/psych: Gynecology: Weight gain/weight loss, Fever Rash or Easy Bruising Excessive fatigue, Hair loss, Too hot or cold, Hot flashes, ight sweats Chest pain, Shortness of breath, Cough Headache, Depressed mood, Mental or physical abuse Breast changes, Abnormal vaginal discharge, Vaginal dryness, Pain with intercourse, Heavy bleeding, Bleeding between periods, Postmenopausal bleeding, Missed periods Urogynecology: Gastroenterology: Leakage of urine, Urinary frequency, Blood in urine, Pain with urination Abdominal pain, Blood in stool, Constipation, Diarrhea, ausea/vomiting Obstetric History How many times have you been pregnant (including miscarriages, abortions, and deliveries)? How many living children do you have? How many adopted children/stepchildren? Have you had any preterm deliveries (prior to 37 weeks of pregnancy)? es o How many miscarriages? How many elective terminations/abortions? Have you ever had a dilatation & curettage (D&C)? es o For pregnancies that resulted in delivery, please list the date of the delivery, the number of weeks of pregnancy at the time of delivery, the type of delivery (vaginal or cesarean), newborn weight and gender, the location (hospital name or city/state/country), and any complications during the pregnancy, the delivery, and postpartum. Date Weeks Delivery Type Weight/Gender Location Complications

Gynecological History How old were you when you had your first period? If applicable, what was the first day of your last menstrual period? How many days of bleeding do you usually have? Are your periods regular (every 25-35 days)? es o Please describe any menstrual irregularities or concerns: Have you completed the Gardasil vaccine (against Human Papilloma Virus (HPV))? es o Do you have a history of sexual activity with anyone? es o Are you currently sexually active? es o Is your partner Male Female What birth control do you use (e.g., birth control pill, condoms, IUD, explanon, tubal ligation, partner had a vasectomy, withdrawal, natural family planning)? Please circle any of the following sexually-transmitted infections you have had: Genital Warts Genital Herpes Gonorrhea Please circle any history of the following: Breast Disease/Biopsy Abnormal Mammogram Infertility Chlamydia HIV/AIDS Syphilis PCOS/Amenorrhea Endometriosis Abnormal Pap Smear/LEEP Hepatitis Pelvic Inflammatory Disease (PID) Exposure to Diethylstilbestrol (DES) Uterine Anomaly (e.g., bicornuate uterus) If applicable, please list the most recent date, results, and recommended follow-up for the following screenings: Month/ear Result (ormal/abnormal) Recommended Follow-up Colonoscopy Bone Density/ DEXA Mammogram Pap smear Medications What medications do you regularly take? Please include prescriptions, over-the-counter medications, vitamins, herbs and supplements. Please also include the dose. 2

Personal Health History Anemia Do you have a history of any medical condition listed below? ES O DETAILS (DATE, AGE, DESCRIPTIO) Blood Clotting Disorder/ Thrombophilia Stroke/ Venous Thromboembolism /DVT Blood Transfusion von Willebrand Disease/ Bleeding Disorder Heart Disease/Heart Attack High Blood Pressure Arthritis Autoimmune Disorder/Lupus Asthma Cancer Diabetes (Gestational, Type 1 or Type 2) Thyroid Disease/Dysfunction Osteopenia/Osteoporosis/ Fragility Fracture Depression/ Postpartum Depression Psychiatric Illness/ Eating Disorder History of Trauma/Violence/ Suicidality Epilepsy/Seizures Headaches/Migraines Hepatitis/Liver Disease Gastrointestinal Illness Kidney Disease/Frequent UTIs Skin Disorder/ Eczema/Psoriasis HIV/AIDS Tuberculosis/Exposure to TB Please list any healthcare providers who help you to manage a chronic health condition (e.g., Primary Care Physician, Cardiologist, Endocrinologist, Psychiatrist, etc.): 3

Have you ever had an allergic reaction to a medication or vaccine? es o If yes, please list and describe reaction: Do you have any other allergies or reactions? Please list all hospitalizations and surgeries that you have had, the date, and the hospital location: Month/ear Hospitalization/Surgery Hospital Location Please list any complications from surgery: Do you or any of your blood relatives have a history of problems with anesthesia? es o Do you have any objections to any form of medical treatment (e.g., blood transfusion)? es o If yes, please describe: Social History/Health Exposures Do you exercise regularly? es o Do you feel safe where you live? es o Please list any current and past use of tobacco/nicotine products and/or illegal/recreational drugs: How many servings of alcohol do you consume each week? Please list any history of alcohol or drug dependence or other addictions: 4

Family Health History Mother: Living Deceased (Age/Cause of Death): Father: Living Deceased (Age/Cause of Death): Sisters: Brothers: Daughters: Sons: Have any of your blood relatives been diagnosed with any of the conditions listed below? Please include your parents, siblings, and children. Family cancer history will be requested on the next page. Diabetes ES O DETAILS (WHICH RELATIVE, WHAT AGE) Heart Disease/Heart Attack High Blood Pressure High Cholesterol Blood Clotting Disorder/ Thrombophilia Stroke/ Venous Thromboembolism /DVT Mental Illness Osteoporosis/Broken Hip Autoimmune Disease Kidney Disease Hereditary Breast and Ovarian Cancer Syndrome/ BRCA mutation Lynch Syndrome Sickle Cell/Thalassemia/Hemoglobinopathy Fragile X 5

Please indicate below whether OU or a BLOOD RELATIVE have/has been diagnosed with any of the cancers listed. Indicate FAMIL RELATIOSHIP and AGE AT DIAGOSIS. Siblings/Children our mother's our father's side ou (Who + age at side (Who + age at Please Age you diagnosis) (Who + age at diagnosis) circle were Ex: Brother, 36 diagnosis) Ex: Grandpa, 65 diagnosed yrs Ex: Aunt, 44 yrs yrs Breast cancer Breast cancer in both breasts or multiple primary breast cancers Ovarian cancer (OT benign ovarian cysts) Male breast cancer Uterine (endometrial) cancer (OTE: do not include cervical cancer) Colon cancer Stomach, kidney/urinary tract, brain, or small bowel/intestinal cancer 10 or more colon polyps found in a lifetime Metastatic or high-grade prostate cancer (Gleason score greater than 6) Pancreatic cancer Malignant melanoma Other cancers not listed above Are you of Ashkenazi Jewish descent? es o Have you or someone in your family been diagnosed with a BRCA 1 or 2 OR a Lynch mutation? es o Patient s Signature: Date: For Office Use Only: Patient meets criteria for hereditary cancer testing? es o If ES: ACCEPTED DECLIED 6 Physician s Signature: Date:

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