Adult Health History for New Patient

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Adult Health History

Adult Health History for NEW Patients

Adult Health History for NEW Patients

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Transcription:

Adult Health History for New Patient Name: Birth Date: Today s Date: Preferred Pharmacy (name and location): Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. Please fill out all pages. If you cannot remember specific details, please provide your best guess. Medications Please list all prescription and non-prescription medications, vitamins, and any supplements that you take, even on a non-regular basis. Medication Dosage Times per day Allergies Please list all allergies to medications, latex, shellfish or iodine. Allergies Known Side Effects or Reactions 1

Personal Medical History Condition Current Past Comments Alcohol/Drug Abuse Allergies (Hay fever) Anemia Anxiety Arthritis (Rheumatoid/Osteo) Asthma Bladder/Kidney Problems Blood Clot (Leg/Lung) Blood Transfusion Breast Lump (Benign) Cancer (Please List Type) Cataracts Chicken Pox Colon Polyps Coronary Artery Disease Depression Diabetes Diverticulitis Emphysema Fractures (Broken Bones) Gallbladder Disease GERD/Heartburn Glaucoma Gout Gynecological (Endometriosis) Gynecological (Fibroids) Gynecological (Other) Heart Attack Hepatitis (A, B or C) High Blood Pressure High Cholesterol Irritable Bowel Syndrome Kidney Disease/Failure Liver Disease Migraine Headaches Osteoporosis Pneumonia Prostate (Enlargement/Nodules) Seizure/Epilepsy Skin Conditions Sleep Apnea Stomach Ulcer Stroke Thyroid Disease 2

Health Maintenance Screening Tests For Females: Mammogram Date: Normal / Abnormal Pap Smear Date: Normal / Abnormal Bone Density Date: Normal / Abnormal Lipid Panel (Cholesterol) Date: Normal / Abnormal Surgical History For Males: Testicular Exam Date: Normal / Abnormal Prostate Exam Date: Normal / Abnormal Lipid Panel (Cholesterol) Date: Normal / Abnormal Procedure Yes Year Comments Abdominal Surgery Angioplasty (with or without stent) Appendectomy (Appendix Removal) Back Surgery Biopsy (Location) Breast Surgery/Biopsy Carpal Tunnel Colonoscopy Colostomy Coronary Bypass Coronary Stent EGD (Stomach Endoscopy) Cataract Gallbladder Removal Laparoscopic? Yes / No Gastric Bypass Heart Surgery (Other than Coronary Bypass) Hernia Repair Hip Surgery Hysterectomy (Total, including ovaries) Circle: Laparoscopic / Vaginal / Abdominal Hysterectomy (Partial, ovaries left) Circle: Laparoscopic / Vaginal / Abdominal Knee Surgery LASIX LEEP (Cervix Surgery) Neck Surgery Ovary Removal Pacemaker Sigmoidoscopy Sinus Surgery Small Bowel Resection Thyroidectomy Tubal Ligation Vasectomy 3

Mother Father Sister(s) Brother(s) Mom's Mom Mom's Dad Dad's Mom Dad's Dad Other Relative: Family History Disease Comments No Significant History Known ADD/ADHD Alcoholism/Drug Abuse Allergies Alzheimer s Anxiety Asthma Arthritis Autoimmune Disease Bleeding or Clotting Disorder Blood Disease (Please List) Cancer, Breast Cancer, Colon Cancer, Ovarian Cancer, Prostate Cancer, Other Colon Polyps COPD/Emphysema Coronary Artery Disease Depression Developmental Delay Diabetes Genetic Disorders (Explain) Glaucoma Heart Disease Hearing Disease Hepatitis B or C High Blood Pressure High Cholesterol Hip Fracture Kidney Disease Kidney Stones Learning Disabilities Migraine Headaches Mental Illness Obesity Osteoporosis Seizure Disorder Skin Conditions (Please List) Stroke Thyroid Disease 4

Health Issues Social History Tobacco Use: Smoke Cigarettes? Never Former Yes Current Smoker: Packs/day: Number of years: Former smoker: Quit date: How many years did you smoke? Approximately how many packs per day did you smoke? Other Tobacco: Pipe Cigar Snuff Chew Alcohol Use: Do you drink alcohol? No Number of drinks/week: Yes Type: Beer Wine Liquor Caffeine Use: Do you use caffeine? No Yes Number of drinks/day: Type: Chocolate Coffee/Tea Energy Drinks Soda Drug Use: Do you use marijuana or recreational drugs? No Yes Have you ever used needles to inject drugs? No Yes Sexual Activity: Sexually involved currently? No Yes Sexual partner(s) is/are/have been: Male Female History of STDs: No Yes, type: Birth control method: None Needed Condom Pill Diaphragm Vasectomy Occupation (or prior occupation): Employer: Highest level of education: Marital status: Single Partner Married Divorced Widowed Spouse/partner name: Number of children: Women s Health History Total number of pregnancies: Number of births: Age at beginning of periods (menstruation): Age at end of periods (menopause/hysterectomy): Not applicable Date (month/date if known) of last menstrual period: How long do they last? days 5

CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION (HIPAA) Family Physicians of Greeley, PLLP Name: Name of Patient or Guardian Date of Birth: Release of Information I authorize Family Physicians of Greeley, its employees and agents to disclose my health information, including my visit records, diagnoses, treatments and test results, to the person(s) identified below. I understand that any personal health information released to the person(s) identified may be subject to re-disclosure by such person and may no longer be protected by applicable federal and state privacy laws. This information may be released to: Spouse: Child[ren]: This Release of Information will remain in effect until terminated by me in writing. I understand that I have a right to revoke this authorization by providing written notice to Family Physicians of Greeley. However, this authorization may not be revoked if Family Physicians of Greeley, its employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for healthcare services. Messages Please call: my home: my work: my cell phone: other: If unable to reach me: you may leave a detailed message please leave a message asking me to return your call other: The best time to reach me is (days), between (time) Signed: Witness: Date: Date:

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