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Transcription:

Patient Information Date / / First Name Middle Initial Last Name Date of Birth / / Social Security # Gender Male Female Marital Status Single Married Separated Divorced Widowed Address Apt # City State Zip Code Home Phone Cell Phone Work Phone Race & Ethnicity Primary Language Employment Status Employed Self-Employed Unemployed Disabled Retired Student Occupation Email Address Emergency Contact (Name, Relationship, Phone) PHARMACY INFORMATION Name Pharmacy Phone # Pharmacy Address INSURANCE INFORMATION Primary Insurance Company Phone # ID/Subscriber # Group # Subscriber Name Relationship to patient Subscriber SSN Subscriber DOB Secondary Insurance Company Phone # ID/Subscriber # Group # 1

Name Current Medications DOB: Please include all Prescription, Over the Counter, Herbal Medications & Supplements. Medication Dose Frequency Allergies? Yes or No Please list all medications AND reactions. 1. 3. 2. 4. Past Medical History Please list diagnosis (i.e. Diabetes, Hypertension, ect.), age/year at time of diagnosis. 1. 5. 2. 6. 3. 7. 4. 8. Past Surgical History 1. 5. 2. 6. 3. 7. 4. 8. Family History 2

Father o Alive, age o Deceased, age Cause of Death Mother o Alive, age o Deceased, age Cause of Death Siblings # of Brothers # of Sisters Children # of Sons # of Daughters o Prostate Cancer o Testicular Cancer o Breast Cancer o Cervical Cancer o Ovarian Cancer o Breast Cancer o Cervical Cancer o Ovarian Cancer o Prostate Cancer o Testicular Cancer 3

REVIEW OF SYSTEMS CONSTITUTIONAL O CHANGES IN APPETITE O NIGHT SWEATS O FEVER/CHILLS O RECENT WEIGHT LOSS/GAIN O FATIGUE SKIN O CHANGE IN EXISTING SKIN LESION O NEW RASH O NEW SKIN LESION EYES O RECENT VISION CHANGES O DOUBLE VISION O EYE PAIN O EYE EXAM O EAR, NOSE, THROAT O LOSS OF HEARING O SNORING O TROUBLE SWALLOWING O DENTAL EXAM O ALLERGY/IMMUNOLOGY O SEASONAL ALLERGIES O FOOD ALLERGIES HEMATOLOGIC/LYMPHATIC O EASY BRUISING O ENLARGED LYMPH NODES CARDIOVASCULAR O CHEST PAIN O PALPITATIONS O FAINTING O DIFFICULTY BREATHING WHEN LAYING FLAT O LEG SWELLING O LEG PAIN WHEN WALKING RESPIRATORY O WHEEZING O SHORTNESS OF BREATH O COUGH O COUGHING UP BLOOD GASTROINTESTINAL o HEARTBURN o CONSTIPATION o CHRONIC DIARRHEA o CHANGE IN BOWEL HABITS o NAUSEA/VOMITING o BLOOD IN STOOL GENITOURINARY o BLOOD IN URINE o URINARY INCONTINENCE o OVERACTIVE BLADDER ENDOCRINE o HEAT INTOLERANCE o COLD INTOLERANCE o EXCESSIVE URINATION o DIMINISHED SEX DRIVE MUSCULOSKELETAL o JOINT PAIN, REDNESS, SWELLING o MUSCLE PAIN NEUROLOGICAL O HEADACHES O NUMBNESS O TINGLING PSYCHIATRIC o ANXIETY o DEPRESSION o INSOMNIA WOMEN S HEALTH o HEAVY/IRREGULAR PERIODS o BREAST LUMPS/NIPPLE DISCHARGE o MENOPAUSE o PAINFUL SEXUAL INTERCOURSE o POSTMENOPAUSAL BLEEDING MEN ONLY o ERECTILE DYSFUNCTION o TESTICULAR PAIN/MASS o WEAK STREAM 4

Social History Marital Status Single Engaged Married Separated Divorced Widowed Occupation Are you sexually active? Yes No Tobacco Use Yes or No Alcohol Use Yes or No Illicit Drug Use Men Women Both If Current Smoker: # Packs Per Day Years If Former Smoker: # Packs Per Day Years Quit Date If yes, how much and how often? Healthcare Maintenance Please list date of exam/procedure, performing physician, practice and location. Mammogram PAP Smear Bone Density Colonoscopy Prostate/Rectal Exam Immunizations Influenza (Flu) Gardasil (HPV) Hepatitis B,, Tetanus/Tdap (every 10 years) Pneumovax 23 Prevnar 13 MMR (Measles/Mumps/Rubella) Zostavax or Shingrix (Shingles) 5

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