1 Medical History Please complete this form before your Doctor visit. We will review this together and make any changes needed. Name Date of Birth Date of visit What is your height? weight? Medical History, surgical history, including current ailments for which you are receiving medication. 6. 7. 8. 9. 10. 1 1 1 1 1 16. Use extra paper if needed Medication allergies and reaction you experienced Current Medications including vitamins/supplements Dose Frequency 6. 7. 8. 9. 10. 1 1 1 Use extra paper if needed
2 Name Social history: Married, single, widowed, divorced, partnered? Are you working or retired? What kind of work are you doing or did you do? Are you in an assisted living environment? Any recent travel out of the U.S? 6. Do you smoke or use other tobacco products?. If yes, type of tobacco (cigarettes, cigars..) 7. Did you smoke in the past?. Year you quit 8. Do you drink alcohol?, Amount per day or per week? Functional Ability, ADL s (activities of daily living) Do you need assistance with any of the following? y/n Y for yes, N for no Eating Bathing Toileting Walking (independently) Do you use a walker, cane or other device? Dressing Transferring-bed to chair, chair to chair Have you fallen within the past month? Fall Risk Have you fallen within the past three months?, if yes, how many times? Are you able to walk without problems? Do you use a walking aide like a cane or other assist device (walker?) Is your vision intact and can you see well in your environment? Do you have problems with balance? if yes, explain (for example, tremor, coordination, poor strength, problem standing.) Are you aware if your blood pressure drops upon standing? Do you take any medicines that can cause you to faint or lose your balance?, If yes what are they? Do you have an illness that impairs the feeling in your feet? Legal documents: Do you have a living will (advanced directive?) If yes, who is the health care power of attorney? Name, contact phone number? If no, would you like to discuss this and get resources? Maryland; http://www.caringinfo.org/files/public/ad/maryland.pdf Virginia http://www.caringinfo.org/files/public/ad/virginia.pdf D.C. http://www.caringinfo.org/files/public/ad/districtofcolumbia.pdf 2
3 Name The names of other Doctors/health professionals you see routinely? Date of last visit (approximate) Ophthalmologist Gynecologist Endocrinologist Cardiologist Dentist 6. Podiatrist 7. Others.. 8. Screening Tests When was your last colonoscopy? When was your last Mammogram?, results? When was your last gynecology visit? When was your last Bone density test? When was your last dental visit?? Frequency of dental visits? Adult Vaccinations: Write down the date as well as you remember. Flu Shot Shingles shot? (Zostavax) Pneumonia shot #1 Pneumovax-13 Pneumonia shot #2, Pneumovax-23 Regular tetanus Shot 6. Tdap (Tetanus with pertussis) Hospitalizations: Have you been a patient in a hospital overnight within the past 12 months? 3
PATIENT HEALTH QUESTIONNAIRE (PHQ-9) NAME: DATE: Over the last 2 weeks, how often have you been bothered by any of the following problems? (use "ⁿ" to indicate your answer) Not at all Several days More than half the days Nearly every day Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead, or of hurting yourself add columns + + (Healthcare professional: For interpretation of TOTAL, please refer to accompanying scoring card). TOTAL: 10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Copyright 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD is a trademark of Pfizer Inc. A2663B 10-04-2005
5 Name Family Health History: D=deceased A=alive Mother Father Siblings Male/Female including half bro & sister Children Male/female 6. Use extra paper if needed Age, or if deceased, age at death Medical illnesses within the family? If deceased, cause of death if known? HIV Talk with your Doctor about HIV screening only if any of these apply to you: You have had unprotected sex with multiple partners. You use or have used injection drugs. You exchange sex for money or drugs or have sex partners who do. You have or had a sex partner who is HIV-infected or injects drugs. You are being treated for a sexually transmitted disease. You had a blood transfusion between 1978 and 198 You have any other concerns. 5
6 Name Review of systems Within the past 1 to 3 months check those items which are ongoing or need discussion General; Weight change-more than 5 pounds in six months, night sweats, change in appetite, headaches, insomnia, tired all the time Ear, Nose, Throat; Vision change, tinnitus (ringing ears), hearing loss, Hearing aids, Nose bleeds, Seasonal allergies post nasal drip, Hoarseness, Cardiovascular; Chest pains, fainting, heart palpitations, shortness of breath Pulmonary; Chronic cough, Wheezing, Asthma, Emphysema, Sleep apnea, Gynecologic; Last menstrual period (or post-menopausal,) Abnormal vaginal bleeding, Abnormal periods Breasts; lumps, change in shape, discharge from the nipple. Gastrointestinal; heartburn, nausea, constipation, diarrhea, abdominal pains, change in bowel habits Urinary; Kidney stones, kidney disease, urinary frequency, awaken at night to urinate, painful urination, hard to get the urine stream started, urinary incontinence Skeletal; swollen joints, diminished motion, weakness, leg cramps, arthritis, Joint pains Neurologic; seizures, frequent headaches, strokes, TIA s (mini-stroke), fainting, tremor, memory loss Psychiatric; Depression, anxiety, nervousness, Endocrine; known thyroid disease, overly frequent thirst, very frequent urination Hematologic; bleeding, easy bruising, anemia, blood disorder Skin; hair loss, rashes, skin growths or changes, skin lesions that don t heal, _ 6