Patient Health Histry Name: Date f Birth: Age: SS #: Tday's Date: Sex: Male Height: Female Primary Care Physician: Phne Number: Referring MD: Phne Number: Other MD's: Name/Specialty Pharmacy Name: Pharmacy Number: Current prblem r reasn fr cnsultatin: D yu feel yu need t be linked t ur scial wrker (cunseling r financial issues)? Yes N PAST MEDICAL HISTORY: Please check all the bxes that apply Allergies Anemia/Bld Disrders Arthritis Asthma Bld Clts Cancer Cataracts Clitis Diabetes Emphysema GERD Glaucma Heart Disease Other: Other: Any unusual childhd infectins r illnesses? OPERATIONS: Please list year, peratin and surgen (if knwn) 1. 2. 3. 4. 5. Hepatitis/Liver Disease Hyperchlesterlemia Hypertensin Irregular Heartbeat Kidney Disease Pancreatitis Sickle Cell Disease Sinusitis Strke Thyrid Tuberculsis Ulcers Revised 3/7/2017 1
ROUTINE CANCER SCREENING TESTS: List last date (if knwn) Mammgram: Breast Exam: Pap Smear/Pelvic Exam: Stl fr Occult Bld: Prstate Exam/PSA: Chest X-Ray: Clnscpy/Sigmidscpy: SOCIAL HISTORY: Marital Status: Number f Children: Age/Sex f Children: Spuse Name: Spuse Occupatin: Patient Occupatin: Highest Level f Educatin: Patient Lives With: Self Child Spuse Parent(s) Sibling(s) Friend Other City f Residence: Have yu cmpleted an advance directive? Yes N Smking Histry Alchl Histry Have yu cmpleted a living will? Yes N Cigarettes Hw Many Years? Cigars Number Per Day Pipe If Quit, When? Beer Hw Many Years? Wine Hw Much Per Day/Week/Mnth? Liqur If Quit, When? Recreatinal Drug Use Bld Transfusins HIV Testing Nutritinal Supplements: Revised 3/7/2017 2
ALLERGIES TO MEDICATIONS: Yes N NAME OF DRUG(S)/TYPE OF REACTION: MEDICATIONS: NAME OF DRUG DOSE (mg r mcg) HOW MANY TIMES DAILY HOW LONG (MONTH/YEARS) Vaccinatins: Please prvide date f last vaccinatin Pneumnia: Flu: Shingles: FAMILY HISTORY: Relative Age, If Living Father Mther Sis/Br Sis/Br Sis/Br Sis/Br Sis/Br Health Prblems If Deceased, Cause Revised 3/7/2017 3
Fr ther relatives such as grandparents, aunts and uncles: Please check all bxes that apply Anemia Diabetes Bld Clts Heart Disease Bld Disrders Hypertensin Cancer Strke Apprximately 10% f cancer is hereditary. If yu are cncerned yur family may be at risk, genetic cunseling may be apprpriate fr yu. Wuld yu like t discuss this with yur physician? D yu have a Living Will? D yu have a Healthcare Pwer f Attrney? Yes N Yes N Yes N Wuld yu like further infrmatin n either f the abve questins? REVIEW OF SYSTEMS: Please check all bxes that apply Yes N GENERAL FEVER WEIGHT LOSS FATIGUE CHILLS WEIGHT GAIN NIGHT SWEATS HEAD HEADACHES RINGING IN EARS TOOTHACHE BLACKOUTS SINUSITIS DOUBLE VISION SEIZURES POST NASAL DRIP BLURRED VISION DIZZINESS SORE THROAT CATARACTS HEARING LOSS HOARSENESS GLAUCOMA EARACHE SORE TONGUE LAST EYE EXAM BLEEDING GUMS NOSEBLEEDS CHEST COUGH SHORTNESS OF BREATH HEART MURMUR SPUTUM CHEST PAIN RHEUMATIC FEVER COUGHING UP BLOOD PALPITATIONS HIGH BLOODPRESSURE WHEEZING SWELLING OF FEET LAST CHEST X-RAY BRONCHITIS ASTHMA NECK LUMPS GOITER PAIN OR STIFFNESS BREAST ABDOMEN LUMPS PAIN PLE DISCHARGE NAUSEA ABDOMINAL PAIN CONSTIPATION VOMITING HIATAL HERNIA DIARRHEA PAIN WHEN SWALLOWING DIFFICULTY SWALLOWING ULCER HEMORRHOIDS GAS BLOOD IN STOOLS INDIGESTION BLOATING BLACK STOOLS Revised 3/7/2017 4
CONTINUE REVIEW OF SYSTEMS: Please check all bxes that apply URINARY/GYN BLOOD IN URINE BURNING WITH URINATION FREQUENT URINATION DIFFICULTY STARTING TO URINATE BLADDER/ KIDNEY INFECTIONS GETTING UP AT NIGHT TO URINATE # OF PREGNANCIES # OF MISCARRIAGES SPOTTING # OF ABORTIONS CRAMPING # OF CHILDREN DISCHARGE LAST MENSTRUAL PERIOD VAGINAL INFECTIONS DURATION LAST PAP SMEAR SENSE OF FULL BLADDER INTERVAL SKIN NEURO- MUSCULAR HEMATOLOGICAL RASH ITCHING JOINT STIFFNESS SWELLING NIGHT CRAMPS JOINT PAIN BACK PAIN VARICOSE VEINS EASY BRUISING OR BLEEDING CHANGE IN HAIR OR NAILS ANEMIA PAST INFUSION TRANSFUSION REACTIONS ENDOCRINE THYROID PROBLEMS HOT OR COLD INTOLERANCE EXCESSIVE THIRST OR HUNGER PSYCHIATRIC ANXIETY DEPRESSION MEMORY LOSS NERVOUSNESS PATIENT'S SIGNATURE: PHYSICIAN'S SIGNATURE: Revised 3/7/2017 5