PERSONAL HISTORY CURRENT HEALTH CONDITION

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Transcription:

PERSONAL HISTORY Name: Date S.S.# Address: City: State Zip code Home phone Cell Other: E-Mail Date of Birth Age Sex Male Female Business/Employer Address Type of Work Years Employed Check One Married Single Widowed Separated Divorced # of Children Name of Emergency Contact Relation Phone Who is responsible for your bill? Self Spouse Workmans Comp Medicare Medicaid Auto Commercial Personal Health Insurance Other Please answer the following Government Question: What is your race: Caucasian Black Asian Pacific Islander Hispanic Refused to answer What is you Religion: What is your Native language? CURRENT HEALTH CONDITION Purpose of this Appointment Hospital or doctors seen for this condition When & how did this condition begin (describe) If disabled from work please give dates Job related Auto related Other Are you presently taking any medication Yes No

Patient History Patient Name: Date: Date of Birth: Domestic Situation With whom are you living? Are there any substance abuse issues in the household? Yes No Are you able to take care of yourself? Yes No If not, please enter the name of your caregiver Work History How many Job Years did you worked? Why did you leave? Legal Matters Are you presently involved in a lawsuit? Yes No If yes please explain Substance use Which of the following drugs or substances, if any, have you used in the past? ( Mark all that applies) Alcohol Cocaine Heroin, Barbiturates Amphetamines Marijuana Other- Occasionally frequently continuously in the past present Do you presently smoke cigarettes or use tobacco in any form? Yes No If not, did you ever smoke cigarettes or used tobacco in any form? Yes No For how many years? How many years ago did you quite? How many packs do (did) you smoke a day?

Medical History Past Medical History Please check if you have had any of the following: Alcoholism CVA Liver Disease Anemia Dementia / Alzheimer s Migraine Anxiety Disc Disease Multiple Sclerosis Arrhythmia DJD Nephrolithiasis Arthritis Depression Obesity Asthma DM Type I Osteoarthritis Atrial Fibrillation DM Type II Osteoporosis Bronchitis Emphysema Prior MI CAD Epilepsy Pulmonary Disease Cancer Type: Fracture Rheumatoid Arthritis Cardiovascular Disease GERD Seizures CHF Glaucoma Sickle Cell Disease Crohn s Disease Hepatitis STD Cirrhosis High Cholesterol Thyroid Disease Colitis Hyperlipidemia TIA Constipation Hypertension Tuberculosis COPD Implanted Medical Devices Ulcers CRF Kidney Disease Valve Problems Other Allergies Reaction Is there any chance you may be pregnant? Yes No Last date of menses: Past Surgical History Please check if you have had any of the following: No prior surgical history Appendectomy Mastectomy Total Knee Replacement D&C Shoulder surgery Total Hip Replacement Hysterectomy Spinal Surgery Tubal Ligation Knee Arthroscopy Tonsillectomy Other Preventive Care Have you had any of the following? If so, please provide the date. Last Complete Physical Exam / / Bone Density / / Colonoscopy / / Mammography / / Flexible Sigmoidocopy / / Chlamydia Screening / / PSA / / HIV Testing / / Stool Occult Blood / / Flu Vaccine / / Stress Test / / Pneumovax / / Routine Eye Exam / / Zoster Vaccine / / Dilated Eye Exam / / Tdap Vaccine / / Foot Exam / / TD / / HPV Tuberculin PPD / / Other General Family History Ankylosing Spondylitis Colitis Kidney Disease Arthritis COPD Liver Disease Alcoholism Crohn s Disease Osteoarthritis Anemia CVA / TIA Osteoporosis Anxiety Depression Psoriasis Asthma Diabetes Pulmonary Disease Bleeding Disorder Epilepsy Renal Disease CAD GERD Rheumatoid Arthritis MI s Gout SLE CHF Hypertension Thyroid Disease Other Name: Date:

Review of Systems Please check if you have the following symptoms: Constitutional Loss of appetite Recent change in weight Fatigue (Tired) Fever Chills Night Sweats Able to perform ADL s independently Change in sleep habits Head & Neck Headache Vision Problems Eye Pain Ear pain Hearing difficulty Sinus Problems Difficulty Swallowing Neck Stiffness Goiter Cardiovascular Chest Pain Ankle edema Cold hands or feet Palpitations Heart murmur Claudication Respiratory Persistent cough Productive cough Shortness of breath Dyspnea (Difficulty Breathing) Orthopnea Chest congestion Gastrointestinal Nausea Vomiting Diarrhea Constipation Hematochezia Abdominal Pain Genitourinary Frequency Burning on urination Incontinence Hesitancy Dysuria Urgency Endocrine Polyuria (Frequent Urination) Polydysia (Excessive Thirst) Sexual Complaints Heat intolerance Cold intolerance Musculoskeletal Joint Pain Radiculopathy Fractures Back Pain Joint Stiffness Sudden unexplained fractures Neurological Ataxia Seizures Dizziness Numbness Tingling Confusion Speech Difficulties Motor Disturbances Sensory Disturbances Psychiatric Anxiety Depression Panic Attacks Suicidal Thoughts Suicide Attempts Sleep Disturbances Mood Disorders Emotional Problems Depression Screening Completed Hematology / Immunology Easy Bleeding tendency Easy Bruising tendency Swollen Nodes Environmental Allergies Frequent Infections Food Allergy

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