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Adult Health History 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 update form you can use. Please fill in all five 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! PATIENT NAME TODAY S DATE DATE OF BIRTH Main reason for today s visit: Other concerns: What are your health goals for the next year? Where were you getting your healthcare before? In the past two weeks, have you been bothered by: Little interest or pleasure in doing things? Feeling down, depressed, or hopeless? REVIEW OF SYMPTOMS Please check and circle any persistent symptoms you have had in the past few months. Read through every section and check no problems if none of the symptoms apply to you. List other concerns above. GENERAL Unexplained weight loss / gain Unexplained fatigue / weakness Fall asleep when sitting, day Fever or chills SKIN New or change in mole Rash / itching BREAST Breast lump, pain, nipple discharge EARS/NOSE/THROAT Nosebleeds, trouble swallowing Frequent sore throats, hoarsness Hearing loss / ringing in ears EYES Change in vision / eye pain / redness CARDIOVASCULAR Chest pain / discomfort Palpitations (fast or irregular heartbeat) RESPIRATORY Cough / wheeze Loud snoring / altered breath Shortness of breath w/ exertion GASTROINTESTINAL Heartburn / reflux / indigestion Blood or change in bowel movement Constipation GENITOURINARY Leaking urine Blood in urine Page 1 of 7

Nighttime urination or increased frequency Discharge: penis or vagina Concern w/ sexual function MUSCULOSKELETAL Neck pain Back pain Muscle / join pain ENDOCRINE Heat or cold sensitivy HEMATOLOGIC/LYMPHATIC Swollen glands Easy bruising NEUROLOGICAL Headache Memory loss Fainting Dizziness Numbing / tingling Unsteady gait Frequent falls ALLERGIC / IMMUNE Hay fever / allergies Frequent infections PSYCHIATRIC Anxiety / stress / irritability Sleep problems Lack of concentration WOMEN ONLY Premenstrual symptoms (bloating, cramps, irritability) Problem with menstrual periods Hot flashes / night sweats IMMUNIZATIONS: Check off any vaccinations you have had. Add year, if known. Check this box if you don t know the information: Tetanus (Td) Varicella (Chicken Pox) shot or illness Influenza (flu shot) Hepatitis B Zostavax (shingles) Tetanus w/ Pertussis (Tdap) Pneumovax Hepatitis A MMR HPV WOMEN S HEALTH HISTORY Total number of pregnancies Age at beginning of periods Date of last menstrual period (if still menstruating) Age at end of periods (menopause) MEDICATIONS Please list (or show us your own printed record) all prescriptions and non-prescription medications, vitamins, home remedies, birth control pills, herbs, inhalers, etc. I take no medications MEDICATION DOSE (e.g. mg/pill) HOW MANY TIMES PER DAY? Page 2 of 7

Any allergies or intolerance to medications (include type of reaction)?: I have no allergies PERSONAL MEDICAL HISTORY: Do you have (now) or have you had (past) any of the following conditions? NONE Condition Now Past Comments Alcohol / Drug use Allergy (Hay Fever) Anemia Anxiety Arthritis (Rheumatoid) Arthritis (Osteoarthritis) Asthma Bladder / Kidney Problems Blood Clot (leg) Blood Clot (lung) Blood Transfusion Breast Lump (benign) Cancer Breast Cancer Colon Cancer Other Type Cancer Ovarian Cancer Prostate Cataracts Chicken Pox Colon Polyp Coronary Artery Disease Depression Diabetes (adult onset) Diabetes (childhood onset) Diverticulosis Emphysema Fractures (broken bones) WHERE?: Gallbladder Disease Gastroesophageal Reflux (Heartburn/GERD) Glaucoma Page 3 of 7

Condition Now Past Comments Gout Gynecological Conditions (Endometriosis) Gynecological Conditions (Fibroids) Gynecological Conditions (Other) Heart Attack Hepatitis Type A Hepatitis Type B Hepatitis Type C Hepatitis Other High Blood Pressure High Cholesterol Hip Fracture Irritable Bowel Syndrome Kidney Disease / Failure Kidney Stones Liver Disease Migraine Headaches Osteoporosis Pneumonia Prostate (enlargement) Prostate (nodules) Seizure / Epilepsy Skin Condition (Eczema) Skin Condition (Psoriasis) Skin Condition (Abnormal Moles) Sleep Apnea Stomach Ulcer Stroke Thyroid (Nodule) Thyroid High (Overactive) / Hyperthyroidism Thyroid Low (Underactive) / Hypothyroidism Other (list) Other (list) SURGICAL HISTORY: Please check off any procedure or surgeries. List any abnormal findings or complications. Surgical Procedure No Yes Year Comments Abdominal Surgery Appendectomy (appendix removal) Back Surgery (lumbar) Biopsy (location) Breast Biopsy Breast Surgery Colonoscopy Page 4 of 7

Coronary Bypass Coronary Stent EGD (Stomach Endoscopy) Cataract Gallbladder Removal Circle: Laparoscopic Heart Surgery (other than coronary bypass) Hip Surgery Hysterectomy (total, including ovaries) Circle: Laparoscopic Vaginal Abdominal Hysterectomy (partial, ovaries left) Circle: Laparoscopic Vaginal Abdominal Knee Surgery LEEP (Cervix Surgery) Neck Surgery Ovary Ligation ( Tubal ) Ovary Removal Vasectomy Sigmoidscopy Sinus Surgery Other (list) Are you adopted? Yes* No *If yes, and you do NOT know your family history, please skip to section Other Health Issues. DISEASE No significant history known Alcohol / Drug abuse Allergic Disorder Cancer Diabetes Gastrointestinal Disorder Heart Disease Hypertension Kidney Disease Mental Illness Migraine Headache Myocardial Disorder Respiratory Disorder Seizure Disorder Stroke Syndrome Tuberculosis MOTHER FATHER SISTER(S) BROTHER(S) SURGICAL HISTORY Continued: Surgical Procedure Knee Surgery LEEP (Cervix Surgery) Neck Surgery Ovary Ligation ( Tubal ) Ovary Removal Vasectomy Sigmoidscopy Sinus Surgery Other (list) MOM S MOM MOM S DAD DAD S MOM DAD S DAD OTHER RELATIVES COMMENTS No Yes Year Page 5 of 7

OTHER HEALTH ISSUES Tobacco Use Smoke cigarettes: Never (If you never smoked, please skip to alcohol section) Quit Date: How many years did you smoke? How many packs a day did you smoke? Current smoker: Packs per day: Number of years: Oher tobacco: Pipe Cigar Snuff Chew Alochol Use Do you drink alcohol? Number of drinks per week: Beer Wine Liquor Drug Use Have you used marijuana or recreational drugs? Have you ever used needles to inject drugs? Sexual Activity Sexually involved currently? Sexual partners have been: Male Female Birth control method (circle all that apply): Condom, pill, diaphragm, vasectomy, other Exercise Do you exercise regularly? What kind of exercise? How long (minutes): How often: Diet How would you rate your diet? Good Fair Poor Would you like advice on your diet? Safety Do you use a bike helmet? No bike Do you use seatbelts consistently? Does your home have a working smoke detector? If you have guns in your home, are they locked up? Not applicable Is violence in your home a concern for you? Have you completed any of the following: (please check all that apply) Advance Directive for Helathcare (ADHC) Living Will POLST (Physician Orders for Life Sustaining Therapy) Page 6 of 7

SOCIAL HISTORY Occupation (or prior occupation): If not currently employed, please circle one: Retired Unemployed Leave of absence Disabled Employer: Years of education or highest degree: Marital status (please check one): Single Partner Married Divorced Widowed Other Spouse/partner name: Number of children: Age(s) if under 18 years: Number of grand children: Number of great grandchildren: Who lives at home with you? Leisure activities, group involvement, religion, volunteer work, recent travel: Page 7 of 7

For Internal Use Only: MRN Patient Consent Form for Electronic Exchange of Individual Health Information Please read through the consent form and provide the following information: (Please Print) PATIENT NAME Last First Middle PREVIOUS NAME(S) GENDER: M F STREET ADDRESS / P.O. BOX CITY STATE ZIP CODE PHONE NUMBER EMAIL DATE OF BIRTH (MM) (DD) (YYYY) Nevada Medicaid Patients Please Read: Nevada law mandates that a person who is a recipient of Medicaid or insurance pursuant to the Children s Health Insurance Program may not opt out of having his or her individually identifiable health information disclosed electronically (NRS 439.539). When a patient is no longer a Medicaid recipient, it is the patient s responsibility to change their consent choice, if they choose to do so. Please sign below to indicate your acknowledgement. Consent Choices: (CHECK ONE) Nevada Medicaid Patients are exempt from making a selection. Your choice to give or to deny consent may not be the basis for denial of health services. I CONSENT for all HIE participants to access ALL of my electronic health information (including sensitive information) in connection with providing me any health care services, including emergency care. I CONSENT ONLY IN CASE OF AN EMERGENCY for all HIE participants to access ALL of my electronic health information (including sensitive information) ONLY in the event of a medical emergency. I DO NOT CONSENT for any HIE participants to access ANY of my electronic health information EVEN in the event of a medical emergency. Signature of patient or authorized representative Date Time If I sign this form as the Patient s Authorized Representative, I understand that all references in this form to I, me or my refer to the Patient. Name of Authorized Representative (Printed) Relationship Date Time Address of authorized representative signing this form (please print): Phone number of authorized representative FOR INTERNAL USE ONLY Name of Organization: Name of Witness: As a witness to this Consent, I attest that the above signer is personally known to me or has established his/her identity with me by satisfactory photo ID, insurance card, or other evidence of identity customarily relied upon in health care.

Patient Consent Form for Electronic Exchange of Individual Health Information HealtHIE Nevada is a non-profit organization dedicated to connecting the healthcare community to share information electronically and securely to improve the quality of healthcare services. To learn more about the Health Information Exchange (HIE), read the Patient Information brochure. You can ask the doctor that gave you this form for it, or go to the website www.healthienevada.org. Details about patient information in HealtHIE Nevada and the consent process: 1. How your information will be used and who can access it: When you provide consent, only HealtHIE Nevada participants (such as doctors, hospitals, laboratories, radiology centers, and pharmacies), will have access to your health information. It can only be used to: Provide you with medical treatment and related services. Evaluate and improve the quality of medical care provided to all patients, using de-identified health information. 2. Types of information included and where it comes from: The information about you comes from organizations that have provided you with medical care, and are HealtHIE Nevada participants. These may include hospitals, physicians, pharmacies, clinical laboratories, and other healthcare organizations. Your health records may include a history of illnesses or injuries you have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medications your doctor has prescribed. This may include information created before the date of this Consent Form. This information may relate to sensitive health conditions, including but not limited to: Alcohol or drug use problems HIV/AIDS Birth control and abortion (family planning) Genetic (inherited) diseases or tests Mental health conditions Sexually transmitted diseases 3. Improper Access or Disclosure of your Information: Electronic information about you may be disclosed by a participating doctor to others only to the extent permitted by Nevada State Law. If at any time you suspect that someone who should not have seen or received information about you has done so, you should notify your doctor. 4. Effective Period: Your consent becomes effective upon signing this form and will remain in effect until the day you revoke it or HealtHIE Nevada ceases to conduct business. 5. Revoking your consent: At any time, you may revoke your consent by signing a new consent form and giving it to your doctor. These forms are available at your doctor s office, or by calling 855-484-3443. Changes to your consent status may take 24-48 hours to become active in the system. Note: Organizations that access your health information through HealtHIE Nevada while your consent is in effect may copy or include your information into their own medical records. Even if you later decide to withdraw your consent, they are not required to return it or remove it from their records. 6. How your information is protected: Federal and State laws and regulations protect your medical information. HIPAA, the Healthcare Insurance Portability and Accountability Act of 1996, is the federal law that protects your medical records and limits who can look at and receive your health information, including electronic health information. HIPAA s protections were further strengthened by another federal law, the HITECH Act of 2009, which may impose severe financial fines on anyone who violates your medical privacy rights. All health information made available on the HIE, including your medical information, is encrypted to federal standards and is accessible only as allowed by Nevada State law (NRS 439.590). In addition, your doctor must provide you with a Notice of Privacy Practices, which describes how he or she uses and protects your medical information. Copy of Form: You are entitled to receive a copy of this Consent Form after you sign it.

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