PATIENT HEALTH HISTORY

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Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason for your appointment? PATIENT HEALTH HISTORY This questionnaire will help your doctor understand more about you and your medical problems. Is there anything you wish to discuss in addition to the reason your appointment was scheduled? MEDICATION HISTORY LIST THE SPECIFIC NAMES (S) OF THE MEDICATIONS YOU TAKE REGULARLY, THEIR STRENGTH AND HOW OFTEN. REFER TO THE LABEL ON YOUR MEDICINE CONTAINERS IF NECESSARY NAME STRENGTH HOW OFTEN NAME STRENGTH HOW OFTEN 1 6 2 7 3 8 4 9 5 10 1 2 3 MEDICINE MEDICATION ALLERGIES WRITE IN THE NAMES OF ANY MEDICINES OR SHOTS TO WHICH YOU HAVE EVER HAD A BAD REACTION OR ALLERGY. IF NONE, PLEASE WRITE "NONE". REACTION PAST MEDICAL HISTORY HAS A DOCTOR EVER SAID YOU HAD ANY OF THE CONDITIONS BELOW Anemia Arthritis Asthma Cancer Colon or bowel disease Diabetes Emotional problems Emphysema Epilepsy

PAST MEDICAL HISTORY - continued Gallstones Glaucoma Gout Hay fever Heart disease (heart attach, heart failure, angina) Heart murmur as an adult High blood pressure Kidney or bladder infections Kidney or bladder stones Liver disease (cirrhosis, hepatitis) Migraine headaches Psoriasis Stomach or duodenal ulcer Stroke Thyroid disease Tuberculosis HAVE YOU IN THE PAST YEAR, HAD CLOSE CONTACT WITH ANYONE WHO HAD TUBERCULOSIS? HAVE YOU EVER HAD A POSITIVE SKIN TEST FOR T.B.? HAVE YOU EVER HAD A VACCINATION FOR T.B.? Venereal disease WHEN WAS YOUR LAST IMMUNIZATION FOR TETANUS (Lockjaw)? ARE YOU HEPATITIS B POSITIVE OR HAVE YOU HAD THE VACCINE? HAVE YOU RECEIVED PNEUMOVAX VACCINE (to prevent Pneumonia)? Other (list) OPERATIONS OR HOSPITALIZATION OPERATIONS Date Date Appendix Joint arthroscopy / replacement Breast Kidney Cataract Prostate Colon Stomach Gallbladder Thyroid Heart Bypass Vasectomy Hernia (rupture) Other hospitalizations or surgeries INTERVAL HISTORY IN THE PAST YEAR HAVE YOU HAD ANY SERIOUS ILLNESS, SURGERY OR INJURY? If yes, describe IN THE PAST YEAR HAVE YOU BEEN HOSPITALIZED? If yes, when and reason for hospitalization

ARE YOU CURRENTLY HAVING ANY OF THE FOLLOWING PROBLEMS? CHECK HERE IF NONE OF THE FOLLOWING APPLY Have you had unexplained fevers? Blood in urine Unexplained weight loss (more than 5 lbs. in 3 months)? Trouble with eyes or problem with vision? Trouble with your ears Are you concerned that you may be at risk for developing sexually transmitted diseases? Do you have a loss of sexual interest or difficulty in performance that concerns you? se bleeds Pain or swelling in your joints Persistent hoarseness Frequent headaches Persistent cough Dizzy spells or blackouts Coughing blood Skin rash or changes in a mole Trouble breathing or shortness of breath Increased thirst or urination Heart trouble Thyroid trouble (goiter or swelling) Chest pain or pressure Easy bleeding Palpitations Swollen glands Problems breathing when you lie down? Allergies such as hay fever or asthma Swelling in legs? Do you have difficulty sleeping? Pain in legs which forces you to stop walking? Tired or rundown Trouble swallowing Nervous, depressed or emotional trouble Nausea or vomiting, frequent Diarrhea, frequent In the past year have you often found that your worries made you feel unwell a lot? Constipation Blood in bowel movement Black stools Abdominal or stomach pain Indigestion Change in bowel habits? Problems with urination Kidney trouble or infection In the past year has there been a death in your immediate family? Are you now receiving care from a psychologist, psychiatrist or other mental health professional? ARE YOU NOW HAVING SERIOUS OR DISTURBING PROBLEMS WITH YOUR: ( ) Marriage ( ) Family ( ) Drugs ( ) Job or Employment ( ) Financial matters ( ) Other worries. WOMEN ONLY: Lump in breast not previously operated on Discharge or blood from your nipples Did your mother take hormones when she was pregnant with you? Vaginal discharge with burning or itching Are you still having menstrual periods? When did you have your last pap test? If yes, when was your last period? Bleeding between periods When did you have your last mammogram? Vaginal bleeding, although you no longer have regular periods Age at menopause Are you now pregnant? Have you ever been pregnant? If yes, how many children do you have? How many miscarriages or abortions? Do you take birth control pills? Do you use other types of birth control? If yes, what type? Have you ever had German measles (rubella)? Have you ever had German measles vaccination?

PERSONAL HISTORY Have you ever smoked? How many packs a day? ( ) cigarettes ( ) pipe ( ) cigars How long have you smoked? ( ) other Are you still smoking? When did you quit? In the past year did you drink any alcohol? If yes, how many alcoholic drinks did you usually have (wine, beer, whiskey, cocktails)? ( ) Total of 6 or more a day ( ) 3 to 5 a day ( ) 1 or 2 a day ( ) Only occasionally Do you think you drink too much alcohol? Have you ever had a drinking problem for which you received treatment or which you got over by yourself? Have you ever felt you should cut down? Have people annoyed you by criticizing your using or drinking? Have you ever felt bad or guilty about your drinking or using? Have you ever had a drink to get you started when you wake up? Do you use recreational drugs? If yes, what kind? ARE YOU NOW: ( ) Married ( ) Number of Marriages ( ) Never Married ( ) Divorced ( ) Widowed ( ) Separated Do you have children? How many? What are their ages? If you have adult children, are they local? OCCUPATION: HAVE YOU EVER WORKED IN A PLACE WHERE YOU WERE OFTEN OR DAILY AROUND: Solvents or cleaning fluids X-ray or radioactivity Insect or plant sprays Lead or metal dusts or fumes Plastic or resin fumes Very loud noises Asbestos Radar or microwave Silica, sandblasting, grinding/drilling dust Where were you born? EDUCATION: Highest grade you completed: ( ) 0-9 ( ) 10-12 ( ) Tech./Bus. ( ) Partial College ( ) College Graduate ( ) Post Graduate Do you feel you eat a healthy diet? Do you follow a specific diet? If yes, what kind? Do you drink coffee, tea or cola drinks? If yes, how much? Do you exercise regularly? Are you ( ) Heterosexual ( ) Homosexual ( ) Bisexual Do you wear your seatbelt?

FAMILY HISTORY IF ANY BLOOD RELATIVE HAVE HAD ANY OF THESE CONDITIONS, PLEASE CHECK WHO. Father Mother Brother or Sister Sons or Daughters Cancer Which part of the body? Emphysema Heart Attack High Blood Pressure Sickle Cell Anemia Stroke Suicide or mental illness Tuberculosis WRITE IN ANY CONDITIONS NOT LISTED ABOVE THAT RUN IN YOUR FAMILY: Father Mother Brother(s) Sister(s) FAMILY AGE IF LIVING AGE AT DEATH CAUSE OF DEATH

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