Women s Health. Allergies Medication, Food, or Substance (List below) What happens? (Symptoms or reactions) When did this occur?

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Transcription:

For Office Use Only: HT: WT: B/P: / R: P: Age: Urine Results: Glu: Ket: Blood: Protein: Nitrites: Leuk: Your DaVita Medical Group medical record is becoming electronic. Help us enter accurate information about you by answering the following questions: Allergies Medication, Food, or Substance (List below) What happens? (Symptoms or reactions) When did this occur? Do you have allergies to Latex? No Do you have allergies to Contrast Dye? No Medications (Current) of Medication Dose/Frequency Reason or Condition

Page 2 of 8 Social History (write answers and check spaces as needed): Employment Marital Status Sexual Orientation Sexually Active Education Smoking Alcohol Caffeine Full time Part time Retired Unemployed In School Permanently Disabled Partially Disabled Your occupation: Single Married Divorced Widow Partner Heterosexual Same sex Both sexes Transgender Other Comments: No Same partner for years Multiple partners With Males Females Both High School Bachelor s Master s Doctorate or years completed: Never Previous (past) smoker Recently stopped Smoking now # per day for how many years Quit (date) Smoked packs per day for years Chew tobacco Frequency Drink alcohol Type: Frequency: Never drink alcohol Recovering alcoholic Stopped drinking alcohol Alcohol use during pregnancy No how much Regular Exercise No Type: Frequency: Seatbelt Use Living in Living Environment Leisure, Recreational or Sports Activities Learning Disability [PMH] Recreational Drug Use/Substance Abuse [PMH] Are you on a special diet? No Home Apartment Hospice Nursing home Assisted living facility Halfway house Homeless Also Homebound Secure and Safe Fear of other Occupants No Type: Route: Frequency: Past Drug Abuse: No No Details:

Page 3 of 8 Past Medical History: ONLY CHECK YES IF APPLIES TO YOU History of: When? History of: When? Alcohol Abuse Problem Cancer Ovarian Anemia Cancer Uterine Anxiety Cancer Colorectal Arthritis (Rheumatoid) Cancer Lung Arthritis (Osteo or Cancer Colon Degenerative) Asthma Cancer Prostate Bleeding Tendency Cancer Skin Melanoma Bladder/Urinary Cancer Skin Basal Cell infection Blood Clots: Legs (deep Cancer Other vein thrombosis) Blood clots: Lung Cirrhosis (pulmonary embolus) Blood Transfusion COPD/Emphysema Breast Problems Cancer Lung Cancer Breast Diabetes Depression Low Back Pain Epilepsy Liver Disease Type: Gall Bladder Disease Migraine Glaucoma Multiple Sclerosis Gout Osteoporosis/ Osteopenia Hay Fever Pap Smear Abnormal Heart Attack Parkinson s Disease Heart Disease Pelvic Inflammatory Disease Heart Failure Parkinson s Disease Heartburn/GERD/ Kidney Stone Reflux

Page 4 of 8 Past Medical History: ONLY CHECK YES IF APPLIES TO YOU History of: When? History of: When? High Blood Pressure (Hypertension) Kidney Failure, Type: High Cholesterol Shingles (Hypercholesterolemia) Hives/Urticaria Skin Condition Hepatitis B Sleep Apnea Hepatitis C Stroke Thyroid Low (Hypothyroidism) Sexually Transmitted Disease: Chlamydia infection (penile or vaginal) Genital Herpes Gonorrhea Other venereal disease HPV

Page 5 of 8 Family History Do you have children? No If yes, how many? History of (check if yes ): Father Mother Brother Sister Other Alcohol Abuse Problem Alzheimer s/dementia Arthritis Asthma Cancer, Breast Cancer, Ovarian Cancer, Uterine Cancer, Colorectal Cancer, Lung Cancer, Colon Cancer, Prostate Cancer, Skin Melanoma Cancer, Skin Basal Cell Cancer, Other Depression Diabetes Hay Fever Heart Attack High Blood Pressure (hypertension) High Cholesterol (hypercholesterolemia) Liver Disease, Type: Migraine Kidney Failure, Type: Stroke Other: Adult Prevention History Test Test Result Where & Approx Date Bone Density (BXA) BRCA Testing Mammography Pap Smear Colon cancer screen with colonoscopy, barium enema, flexible sigmoidoscopy or stool cards

Page 6 of 8 Adult Prevention History (Cont.) Test Test Result Where & Approx Date Colorectal Screening If you have asthma, COPD or emphysema: Pulmonary Function (Breathing) Test If you have diabetes: Foot Exam No Dilated eye examination No VACCINATIONS: H1N1 (Swine Flu) No Hepatitis A No Hepatitis B No Herpes zoster (shingles) No Human Papillomavirus (HPV) No Influenza (Flu) No Measles, Mumps, Rubella (MMR) No Meningococcal No Pneumococcal (pneumonia) No Tetanus or Tetanus/diphtheria (Td) or Tetanus/Diphtheria/Pertussis (Tdap) No Varicella (chicken pox) No Past Surgical History Surgery: Description (if known): Approx. Date Appendix Bladder Blood vessel Eye Ear Gall Bladder Heart Joint Pelvic Prostate Stomach Skin Uterus (Cesarean, Hysterectomy) Other

Page 7 of 8 Current Female Health History Last pap smear Results: Last mammogram Results: Age @ Menstrual Period 1 st Day of Last menstrual period Number of pregnancies Number of deliveries Number of Miscarriages/ abortions Method of contraceptive/ how long? Frequency of Periods Gynecologic Problem Menopausal Irregular or missed menstrual How periods Long? Type: Any Problems with Method? Current Male Health History Prostate Problem Type: Urine Flow Problem Have you been counseled about the pros/cons of PSA prostate cancer screening? Have you had a prostate biopsy? Results: Review of Systems DATE: Patient: please check below if you have any of the following problems: SYSTEM 1. General 2. Eyes 3. Head & Neck Ears, Nose, Mouth, Throat DESCRIPTION Weight Loss # lbs: Weight Gain # lbs: Fever Glasses/Contact Lenses Vision Changes Headache Stiffness Ringing in Ears Sinus Infections Mouth Sores PROVIDER COMMENTS (Document for all positive findings)

Page 8 of 8 Patient: please check below if you have any of the following problems: Difficulty Breathing when lying down 4. Heart/Circulation Swelling in legs Irregular heart rate 5. Lungs/Breathing 6. Digestion/Bowels 7. Kidneys/Bladder 8. Reproductive 9. Muscles/bones 10. Skin/Breasts 11. Nervous System 12. Mental/Emotional 13. Endocrine 14. Blood/Lymphatic Shortness of breath Wheezing Coughing up blood Nausea/Vomiting Gas Constipation Diarrhea Bloody Stools Blood in Urine Painful Urination Urgency Frequent Urination Incomplete Emptying Incontinence Abnormal Bleeding Pain with Intercourse Muscle Weakness Rash Itching Breast Pain Discharge Lump Bleeding Fainting Seizures Numbness Problems Walking Anxiety Crying Depression Insomnia Diabetes Type: Hot flashes Low Thyroid Overactive Thyroid Bruises Clotting Problems Swollen Lymph Nodes Reason for Visit Today: Health Concerns Today: Completed by: Patient Other Relationship to Patient: Additional Provider Comments:

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