MGH Beacon Hill Primary Care New Patient Form

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Transcription:

MGH Beacon Hill Primary Care New Patient Form For Office Use Only Date Reviewed By Name Date of birth Medical History Please check all that apply. Alcoholism Angina or heart attack Anorexia/bulimia Arthritis Asthma Back pain Blood clots Blood disorder/anemia Blood transfusion (1980-1985) Brain injury Cancer (including skin cancer) Cholesterol elevation Depression Diabetes Drug abuse Emphysema Gynecological disorder (e.g., uterus, ovary) Hay fever Headaches Heart disease HIV disease Intestinal disorder Heart murmur High blood pressure HIV disease Intestinal disorder Intravenous drug use Kidney disease/stones Liver disease or hepatitis Loss of consciousness/seizures Mental illness Mitral valve prolapse Migraines Osteoporosis Pneumonia Prostate disorder Rheumatologic disorders (e.g., RA, lupus) Sexually transmitted diseases Stroke Thyroid problem Tuberculosis Ulcers/gastritis Other: Where have you received medical care most recently? Please indicate any specific concerns about your health.

Please list any other major problems for which you have been under a doctor s care in the past. Surgical History Year Procedure Year Procedure Immunizations/Health Screens Date (month/day/year) Chickenpox Hepatitis B (series of 3) Colonoscopy Measles (MMR) Dental exam Pneumococcal Bone density Sigmoidscopy Eye exam/glaucoma Tetanus shot Flu shot TB test Hepatitis A (Havrix) Date (month/day/year) Current Medications (including non-prescriptions, such as herbs) Prescription name Dosage Frequency Allergies Medication allergies Reaction Food/other allergies Reaction

Family History Please list the age and health status (excellent, good, fair, poor or deceased) for the following relatives. Mother Father Siblings Children Age Health status Please indicate if a blood relative has had any of the following. If yes, indicate his or her relationship to you (e.g., maternal aunt). Alcoholism Asthma Cancer (indicate type) Diabetes High blood pressure Heart disease Mental illness/depression Migraines Kidney disease/stones Osteoporosis Stroke Thyroid disease Ulcer disease Yes Family relationship Lifestyles and Health Habits Do you currently smoke cigarettes? Yes Number of cigarettes per day Have you ever tried to quit? Yes Are you interested in quitting? Do you drink alcohol? Yes Average number of drinks per week (5 oz. glass of wine = 1 drink) Has drinking ever been a concern for you? Yes How many caffeinated beverages (coffee, tea, cola, etc.) do you drink per day? Have you ever used recreational or illegal drugs? Yes Do you follow a special diet? Yes How many servings of fruits and vegetables do you eat per day?

Do you exercise regularly? Yes Do you have trouble sleeping? Yes Does your health make it hard to maintain your daily activities? Yes Do you use seatbelts? Yes Do you use sunblock? Yes Review of Systems Please indicate if you are having concerns about any of the following conditions: General Fever Weight loss Weakness Fatigue Pain Bleeding Lumps Growths Trouble sleeping Eyes Vision problem Redness Excess tears Ears Hearing problem Popping Stuffiness Mouth Tooth problem Difficulty chewing Heart and Lungs Abnormal heart beats Cough Snoring Wheezing Gastrointestinal Difficulty swallowing Heartburn Diarrhea Constipation Blood in stool Black stool Excess gas Genitourinary Difficulty urinating Frequent urination Loss of urine Sexual problem Musculoskeletal Swollen joint Stiff joint Back trouble Neck trouble

Skin Rash Unusual mole Acne Itch Neurologic Numbness Shakiness Difficulty walking Emotional Sadness Anxiety Unusual thoughts Other emotional problems Endocrine Excessive hunger Excessive thirst Heat sensitivity Cold sensitivity Hematologic Infection Black and blue marks Other Problems Social History Relationship status: Single Married Divorced Widowed Opposite sex partner Same sex partner Do you live with others? Yes Do you live with children? Yes Are you currently sexually active? Yes If yes, with: Men Women Both Have you ever been in a relationship with a person who hurt or threatened you? Yes Have you ever been in a relationship with a person whom you have hurt or threatened? Yes Do you have any beliefs, values or ideas that your doctor should know about? Yes Is there anything else you would like to discuss today? Yes

Gynecological History (Female Patients) Number of: Pregnancies Births Miscarriages Abortions Age of first period Last menstrual period Are they monthly? Yes What birth control method do you/would you use? Frequent vaginal infections? Yes Age at menopause Are you having symptoms of menopause? Yes Last pap smear Last mammogram Please indicate if you have ever had the following: Hot flashes Vaginal dryness Other Abnormal mammogram Abnormal pap smear DES exposure Endometriosis Hormone replacement therapy Uterine fibroids Yes Year Diagnosis

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