Clermont Medical Center

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Transcription:

Clermont Medical Center Stephen M. Asmann, M.D. 1135 Lake Avenue, P.O. Box 121009 Carol Takis, PA-C Memory Crowley, D.O Clermont, Florida 34712-1009 Sherri Sartin, PA-C Christopher Guzik, D.O. (352) 394-4035 Russell Kane, PA-C Kelley Winfrey, D.O. Michael Winfrey, D.O. Patient History Form Name: Date: Social Sec. No. Sex: Marital Status: Address: City State Zip: Home Phone: ( ) Cell Phone: ( ) Work: ( ) Birth Date: / / Age: Place of Birth: Occupation Email: Pharmacy: Please check appropriate box (es): African American Hispanic Mediterranean Asian Native American Caucasian Northern European Other What medications are you taking now? List all vitamins and other supplements that you are taking. Medication Name Dosage Vitamins/Supplements Name Dosage Are you allergic to any medications? No Yes If yes please list and reaction. Medication Reaction Past Medical History and Current History: ILLNESSES WHEN COMMENTS Cancer Diabetes Heart Attack/Angina Heart Failure Stroke High blood fat (Cholesterol/Triglycerides) High blood pressure (Hypertension) Sleep Apnea Thyroid Disease Other(describe):

For Men Only: When was your last: (Please list the date) Physical Pneumonia injection PSA (lab work) Zostavax (Shingles) Colonoscopy Tetanus injection Flu shot For Women Only: When was your last: (Please list the date) Physical Pneumonia injection Pap Smear Zostavax (Shingles) Mammogram Tetanus injection Colonoscopy DEXA (bone density test) Flu Shot Have you ever been pregnant? No Yes If yes: Number of miscarriages Number of abortions Number of term births Have you ever used birth control pills? No Yes If yes, when: Are you in menopause? No Yes If yes, age at last period Do you take: Estrogen? Ogen? Estrace? Premarin? Other (specify) Progesterone? Provera? Other (Specify) How long have you been on hormone replacement therapy (if applicable)? Surgery History: Appendectomy Dental Surgery Gallbladder Hernia Hysterectomy Tonsillectomy Other (describe): Year Comments Hospitalizations: Please list only overnight hospitalizations other than surgery or child birth. Where Hospitalized When For what reason

Family History: Relative: Father Mother Brothers Sisters Spouse Son Daughter Paternal Grandfather Paternal Grandmother Age if alive Age of death Cause of death hypertension Cancer Cardiac problems Asthma Diabetes Alzheimer s or dementia Maternal Grandfather Maternal Grandmother Other diseases: Have you ever used tobacco? No Yes Year quit: If yes: every day? some days, but not every day? How many cigarettes a day? 5 or less 6-10 11-20 21-30 31 or more How soon after you wake up do you smoke your fist cigarette? within 5 minutes 6-30 minutes 31-60 minutes after 60 minutes Are you interested in quitting? Ready to quit Thinking about quitting Not ready to quit Tobacco used other than smoking? No Yes Did you have a drink containing alcohol in the past year? No Yes If yes how often: monthly or less 2-4 times a month 2-3 times a week 4 or more times a week How many drinks did you have on a typical day when you were drinking in the past year? 1-2 drinks 3-4 drinks 5-6 drinks 7-9 drinks 10 or more drinks How often did you have 6 or more drinks on one occasion in the past year? Never Less than monthly Monthly Weekly Daily or almost daily Are you feeling down, depressed or hopeless? Yes No Do you feel little interest or pleasure in doing things? Yes No Have you ever used recreational drugs? No Yes When? How much Caffeine daily?

REVIEW OF SYMPTOMS: Please indicate if you have any of the following General: Fever Chills Malaise Fatigue Night Sweats Headache Weight Change Eyes: Ears: Nose: Change in vision Blurring Double vision Pain Date of last eye exam: Did they change your Rx? Hearing loss Pain Discharge Ringing Loss of smell: Obstruction Throat: Hoarseness (Change in voice) Frequent sore throats Sore or bleeding gums Toothaches Change in taste Dentures: Upper Lower Full Partial Endocrine: Thyroid enlargement Pain Tenderness Weight change Heat or Cold Intolerance Excessive Thirst Respiratory: Pain Shortness of breath Wheezing Cough Sputum Production Coughing up blood Exposure to TB Date last Chest X-ray Reason Cardiac: Chest pain Palpitations Ankle swelling Leg cramps High blood pressure Other heart problems: Date of last ECG: other heart tests: Gastrointestinal: Change in appetite Food intolerance Heartburn Nausea Vomiting Constipation Diarrhea Black or Bloody stools Gallstones Hernia Ciarrhosis Hepatitis Jaundice Hematology: Anemia Bleeding problems Blood clots Transfusions Date Reasons Female: Breast lumps Breast Pain Discharge from the breast Menstruation: Heavy bleeding Irregular Missed menses Painful menses Vaginal bleeding between periods Vaginal discharge Hotflashes Painful intercourse Infertility Fibroids Ovarian cyst Endometriosis

Male: Discharge from penis Ejaculation problem Genital pain Impotence Infection Lumps in testicles Poor libido (sex drive) Prostate enlargement Prostate infection Other prostate problem Lymphatic: Swollen Lymph Nodes Pain Urinary: Kidney or Bladder Stones Urinary Tract Infection Blood in Urine Painful Urination Frequency Dribbling Decrease in Force of Stream Musculoskeletal: Back pain Joint pain leg pain swelling in joints Muscle spasm TMJ problems Weakness Cramps Skin: Rash Eruptions Itching Color Change abnormal hair or nail growth Mental: Stroke Paralysis Depression Crying spells Memory loss Loss of balance Suicidal thoughts Please comment on any other information you feel the doctor should know or discuss with you.

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