Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal Past Medical History Diabetes Yes No Emphysema Yes No High Blood Pressure Yes No COPD Yes No Stroke Yes No Pneumonia Yes No Heart Disease/Heart Attack Yes No Depression Yes No Kidney Stones Yes No Bipolar Yes No Thyroid Disease Yes No Mental Illness Yes No Seizures Yes No Dementia (Alzheimer's) Yes No Bleeding Disorder Yes No Ulcers Yes No Sexually Transmitted Disease Yes No Liver Disease Yes No Tuberculosis Yes No High Cholesterol Yes No Rheumatic Fever Yes No Irritable Bowel Syndrome Yes No Asthma Yes No Glaucoma Yes No Anxiety Yes No Osteoporosis Yes No Cancer, type: Yes No Other: Drug/Non-Drug Allergy Allergies Allergic Reaction
Surgical History/ Hospitalizations Previous Surgeries, Hospitalizations and Serious Injuries or Illnesses Date or Age at the time Mother Father Brother/s Sister/s Son/s Daughter/s Maternal Grandparents Paternal Grandparents Family History Year of Birth Living Deceased Age at Death List all Medical Problems Or if they are healthy Use of Tobacco: Social History Never Smoker Former Smoker How long has it been since you last smoked? Current Smoker (If current smoker, answer below questions) Frequency: everyday some days, but not every day First Cigarette after waking up: 5mins 6-10mins 11-20mins 21-30mins >30mins Cigarettes per day: 5 or less 6-10 11-20 21-30 >31 Interest in quitting: Ready to quit Thinking about quitting Not ready to quit Use of Drugs: Never Yes, Type/Frequency
Use of Alcohol: Alcoholic drink in the past year? No Yes (If Yes, answer below questions) Frequency: Never Monthly or less 2-4 X a month 2-3 X a week 4 or more X a week Do you feel safe in your home? Sexual Activity: New Sexual Partner in the past year? Contraception Type: Menstruation: Alarms in your home? Wear seatbelts? Do you wear Sunscreen? Consume Caffeine? Number of drinks on a typical day: 1-2 3-4 5-6 7-9 10 or more Number of times with six or more drinks on one occasion: Never Less than monthly Monthly Weekly Daily or almost daily Yes _ Sexually Active: Yes With whom have you engaged in Sexual Activity with: Men Women Both Yes No Condoms Birth Control, Type: Other: _ne: Date of last period: Any Problems w/ you periods: Smoke Alarms: Yes _ Carbon Monoxide: Yes Yes Yes Yes, Type: _ Frequency: Exercise: No Yes, Type/Frequency Marital Status: Occupation: Traveled outside of the US? Single Married Separated Divorced Widowed Yes If yes, Where: When: _
Name/Specialty Specialist Phone Number Preventative Care Month/Year Location / Hospital Results Bone Density Eye Exam Dental Exam Colonoscopy Mammogram PAP Smear PSA Stool Guaiac Have you had? Pneumonia 23 Vaccine Yes No Prevnar 13 Vaccine Yes No Tetanus Vaccine Yes No Shingles Vaccine Yes No Hepatitis B Vaccine Yes No Hepatitis A Vaccine Yes No Flu Vaccine Yes No Past Immunizations Month/Year
Please Circle any symptoms that you are CURRENTLY experiencing. General/Constitutional Endocrine Night Sweats Generalized Pain Problems w/ Heat Excessive Thirst Poor Appetite Recent Illness Problems w/ Cold Excessive Urination Fatigue Fever Changes in Hair/Skin Weight Change Chills Genitourinary Eyes Problems Urinating Blood in Urine Red Eyes Watery Eyes Bulge in Groin Incontinence Blurred/Double Vision Eye Drainage Decreased Libido Erectile Dysfunction Eye Pain Glasses or Contacts Vaginal Dryness Kidney Stone Date of Last Eye Exam: Concerned about STD's Penile Discharge Frequent Urination ENT Sneezing Problems Hearing Hematology Ear Pain Ringing in ears Abnormal Clotting Swollen Lymph Nodes Hoarse Voice Runny Nose Easy Bleeding/Bruising Anemia Mouth Ulcers Sinus Pain/Pressure Nasal Congestion Sore Throat Musculosketal Nosebleeds Teeth/Gum Issues Back Pain Neck Pain Post Nasal Drip Joint Swelling Date of last dental exam: Dermatologic Respiratory Skin Changes Acne Chronic/Frequent Cough Shortness of Breath Mole Changes Nail Changes Wheezing Excessive Sputum Skin Itching TB Exposure Neurologic Cardiovascular Imbalance Gait Disturbance Leg Pain with Walking Swelling in Legs Numbness Confusion Chest Pain Fainting Memory Issues Headaches Shortness of Breath Palpitations Dizziness Memory Loss Problems Focusing Seizures Gastrointestinal Abdominal Pain Constipation Psychiatric Nausea Diarrhea Sadness Isolation Blood in Stool Hemorrhoids Depression Anxiety Change in Bowel Habits Vomiting Anger Nervousness Low Interest appointment to have them addressed. They may NOT be discussed at a Wellness