Adult Health History for NEW Patients

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Adult Health History

Adult Health History for New Patient

Adult Health History for NEW Patients

Adult Health History for NEW Patients

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Transcription:

Adult Health History for NEW Patients Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is a shorter form you can use. Please fill in all pages. If you cannot remember specific details, please provide your best guess. If you are uncomfortable with any question, do not answer it. Thank you! Main reason for today s visit: Other concerns: What are your health goals for next year? Where were you getting your care before? ADVANCE DIRECTIVES FOR HEALTHCARE (ADHC) Check appropriate box if you have completed any of the following: Living Will Durable Power of Attorney for Healthcare Five Wishes DNR (Do Not Resuscitate) POLST (Physician Orders for Life-Sustaining Treatment) Mammogram Date: Location: Normal Abnormal Pap Smear Date: Provider: Normal Abnormal Colonoscopy Date: Provider: Normal Abnormal Sigmoidoscopy Date: Provider: Normal Abnormal Bone Density Test Date: Location: Normal Abnormal Cholesterol Date: Provider: Normal Abnormal Date Started List All Prescription Medications, Over-The-Counter Medicines, Herbal Supplements or Vitamins: Medication Name and Strength How to take (ex: 1 by mouth twice a day) What time of day is the medication taken? AM Noon Dinner Bedtime As Needed Why are you taking this medication?

List all allergies (Medication, Food, Insect Stings etc): Allergy To: Reaction: Immunization History: Please check this box if you do not know the information Immunization Date Immunization Date Tetanus (Td) Flu Shot Tetanus with Pertussis (Tdap) Hepatitis A Varicella (Chicken Pox) Illness or Vaccine Hepatitis B Pneumonia Vaccine MMR (Measles Mumps Rubella) Meningitis Zostavax (shingles) HPV (Human Papillomavirus) Other Vaccine SOCIAL HISTORY: Occupation (or prior occupation): Current status: Retired Unemployed Leave of Absence Disabled Employer: Years of Education/Highest Degree: Marital Status: Single Partner Married Separated Divorced Widowed Spouse/Partner s Name: Number of Children: Ages: Number of Grandchildren: Number of Great Grandchildren: Who lives at home with you? Leisure Activities, Group Involvement, Volunteer Work, Recent travel TOBACCO USE: Cigarettes: Never Current Smoker - Number of cigarettes per day? How long have you smoked? Former Smoker - How much did you smoke per day? For how long? When did you quit smoking Other tobacco products: Pipe Cigar Snuff Chew ALCOHOL USE: DRUG USE: Do you drink alcohol? Yes No Do you use marijuana or recreational drugs? NO YES Number of drinks per week: Have you ever used needles to inject drugs? NO YES Beer Wine Liquor

WOMEN S HEALTH HISTORY: Total number of pregnancies: Number of births: Age at first pregnancy: Date (Month and date if known) of last menstrual period: Age at first period (menstruation): Age at end of periods (menopause): SEXUAL ACTIVITY Currently sexually active YES NO Sexual partner(s) is/are/have been Male Female Birth control method(s) None Condoms Pill Diaphragm IUD Vasectomy Other EXERCISE and DIET Do you exercise regularly? YES NO What kind of exercise? How would you rate your diet? GOOD FAIR POOR Would you like advice on your diet? YES NO REVIEW OF SYSTEMS: Please explain any persistent problems with any of the following systems in the past few months Skin: Ears: Nose: Throat: Eyes: Heart: Lungs: Stomach: Urinary: Muscles: Swelling: Pain: Depression: Sleep: Other Concerns:

Surgical Procedure Yes Year Comments Abdominal Surgery Appendectomy (appendix removal) Back Surgery (Lumbar) Biopsy (Location) Breast Biopsy Circle: Right Left Both Breast Surgery Circle: Right Left Both Gallbladder Heart Surgery Hip Surgery Circle: Right Left Both Hysterectomy (Partial - Circle: Laparoscopic Vaginal Abdominal leaving ovaries) Hysterectomy (Total, including ovaries) Circle: Laparoscopic Vaginal Abdominal Knee Surgery Circle: Right Left Both Lung Surgery Neck Surgery Ovary Ligation ( Tubal ) Ovary Removal Circle: Right Left Both Vasectomy Sigmoidoscopy Sinus Surgery

PERSONAL MEDICAL HISTORY: Please use the columns on the left if you have (current) or have had (past) any of the following conditions. Feel free to use the comments section to explain. FAMILY MEDICAL HISTORY: Please use the columns on the right if there is family history of the following conditions. Please specify family member Condition Past Current Comments Family Alcohol/Drug Abuse Allergy (Hay Fever) Anemia Anxiety Arthritis Asthma Bladder/Kidney Problems Blood Clot Breast Lump(s) Cancer Any Type Depression Diabetes Gynecological Conditions Heart Problems Hepatitis High Blood Pressure High Cholesterol Kidney Disease / Failure Liver Disease Lung Problems Migraine Headaches Osteoporosis Pneumonia Prostate Problems Seizure / Epilepsy Skin Condition Sleep Apnea Stomach Ulcer Stroke Thyroid Problems History Family member

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