Adult Health History

Similar documents
Adult Health History for NEW Patients

Adult Health History for NEW Patients

Adult Health History for NEW Patients

Adult Health History for New Patient

Patient Information Form

IMMUNIZATIONS: Check off any vaccinations you have had. Add year if known. Check the box if you don t know the information

DONE! You can now close the browser.

Patient Information. Insurance Information

PATIENT NAME TODAY S DATE DATE OF BIRTH

Adult Health History New Patient

Primary Care Clinic Adult Patient Demographics

Name Specialty Number

Comprehensive Patient History Form

ALLERGIES 8. Have you ever had any allergic reaction (bad effect) to a medicine or shot?

Clinic Adult Patient Demographics

An affiliate of Saint Mary's Health System FRANKLIN MEDICAL GROUP, PC. NEW PATIENT INTAKE FORM. Last Name: First Name: DOB: Age:

Adult Health History Form Preferred Name: 1

New Patient Questionnaire. Name DOB Date

Welcome to About Women by Women

NOTICE TO OUR PATIENTS

Do you currently have a family physician?: If not, where have you been getting health care?:

Health History Questionnaire

Women s Health. Allergies Medication, Food, or Substance (List below) What happens? (Symptoms or reactions) When did this occur?

ALLERGIES. If yes, please list the food and non-medication (i.e. latex) allergies and type of reaction you had: MEDICATIONS

NEUROSURGERY PATIENT INTAKE FORM

FROST FAMILY MEDICINE

PATIENT HEALTH HISTORY

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

PATIENT INFORMATION FORM

FAMILY MEDICINE New Patient Medical History Form

SCHNEIDER MEDICAL GROUP, PA History Intake Form (Please Print)

Medical History Form

Medication Allergies

LECOM Health Ophthalmology

EMERGENCY CONTACT INFORMATION: Name of contact: Address: Phone#: Relationship: May we release medical information to this person?

Patient History Form

MGH Beacon Hill Primary Care New Patient Form

Patient Health Forms

NEW PATIENT QUESTIONNAIRE

Medications: Prescription and Non-prescription medications, vitamins, home remedies, birth control pills, herbs.

o Kidney Cancer o Liver Cancer o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine o Neurological

Patient History Form

Initial Consultation

Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:

New Patient Medical Questionnaire DATE:

COMPREHENSIVE HEALTH HISTORY AND HEALTH RISK ASSESSMENT

Southern Maine Integrative Health Center Adult Intake Form

Patient Profile Patient Name: DOB: Address: City: State: Zip: Spouse/Significant Other: Children's names and ages: Patient Employer: Address:

MedStar Medical Group at Forest Hill 1517 Rock Spring Road, Suite C Forest Hill, Maryland Phone (410) Fax (410)

GUPTA SPORTS & SPINE CENTER

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

MEDICAL HISTORY. Previous Nephrologist. Medication taken Insulin Oral Both. Who manages your diabetes? Blindness Yes No Hearing Problems Yes No

Address Street Address City State Zip Code. Address Street Address City State Zip Code

Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code

Heart Attack & Stroke

SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:

GIDEON G. LEWIS, M.D.

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

Patient Name Date of Birth Age. Other phone ( ) . Other

How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all

Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:

Liver Health: Do you have liver problems? Yes No If so, please specify:

New Patient Paperwork

PATIENT HEALTH INFORMATION SHEET

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

Patient Intake Form. Male Female Employment Status Employer Employer Address Employed

Name: DOB: Date: MRN#:

Maineville Family Physician. History and Review of Systems. Name: DOB

PATIENT REGISTRATION

PATIENT HISTORY FORM

Inflammatory Bowel Disease Medical Exam Questionnaire

ADULT INFORMATION SHEET

For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.

PATIENT HISTORY RECORD FACULTY INTERNAL MEDICINE. Date of Appt: / / Name: Date of Birth: / / Last First Middle

Last Name: First Name: MI: 1. Have you recently had any major family changes: If yes, please explain:

This form is long! Please feel free to have the doctor or medical staff help you to complete it if you need any assistance at all.

THE OB/GYN CENTRE NEW PATIENT HISTORY

Mailing Address: Street City Zip

NEW PATIENT INFORMATION FORM

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

FAMILY PRACTICE ASSOCIATES, P.C.

Health History Intake Form;

PATIENT HISTORY FORMS FOR OUTPATIENT CONSULTATION

Patient Health History

DATE OF BIRTH: MELANOMA INTAKE

Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:

Patient Interview Form

Jeri Shuster, M.D., P.A.

Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency

Lehigh Valley Physician Group

Creve Coeur Family Medicine, LLC

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address

Health Questionnaire

University Gynecologic Oncology Associates

Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire

Patient Information: Date: Last Name: Street Address: City: SS #: First Name: Sex: M F Birthdate: Contact Information:

Transcription:

Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit and intake process with our office. If you are uncertain or uncomfortable with a question it can be left blank. IMMUNIZATIONS: Check off any vaccinations you have had. Add year, if known. Check the box if you don t know the information. Tetanus (Td) With Pertussis (Tdap) Varicella (Chicken Pox) shot or illness Pneumovax (pneumonia) Influenza (flu shot) Hepatitis A Hepatitis B MMR Meningitis Zostavax (shingles) HPV MEDICATIONS: Please list (or show us your own printed record) all prescriptions and non-prescription medications, vitamins, home remedies, birth control pills, herbs, inhalers, etc. Use the back of this form if you need more room and let us know you wrote there. TAKE NO MEDICATIONS Medication Dose (e.g. mg/pill) How many times per day? Allergies or intolerance to medications (include type of reaction): NONE HEALTH MAINTENANCE SCREENING TESTS: Lipid (cholesterol) Date Abnormal? No Yes Fasting Blood sugar Date Abnormal? No Yes Sigmoidoscopy or Colonoscopy (circle one) Date Polyp? No Yes Women only: Mammogram Date Abnormal? No Yes Pap Smear Date Abnormal? No Yes Bone Density Test Date Abnormal? No Yes

PERSONAL MEDICAL HISTORY: Do you have now (current) or have you had (past) any of the following conditions? NONE Condition Code Current Past Comments Alcohol / Drug abuse 305.00/305.90 Allergy (Hay Fever) 477.9 Anemia 285.9 Anxiety 300 Arthritis (Rheumatoid) 714 Arthritis (Osteoarthritis) 715.9 Asthma 493.9 Bladder / Kidney Problems Blood Clot (leg) 453.4 Blood Clot (lung) 415.11 Blood Transfusion V58.2 Breast Lump (benign) 611.72 Cancer Breast 174.9 Cancer Colon 153.9 Cancer Other Type Cancer Ovarian 183 Cancer Prostate 185 Cataracts 366.9 Chicken Pox 52.9 Colon Polyp 211.3 Coronary Artery Disease 414 Depression 311 Diabetes (adult onset) 250 Diabetes (childhood onset) 250.01 Diverticulosis 562.1 Emphysema 492.8 Fractures (broken bones) Gallbladder Disease 574.2 Gastroesophageal Reflux (Heartburn/GERD) 530.81 Glaucoma 365.9 Gout 274.9 Gynecological Conditions (Endometriosis) 617.9 Gynecological Conditions (Fibroids) 218.9 Gynecological Conditions (Other) Heart Attack 410.9 Hepatitis Type A 70.1 Hepatitis Type B 70.3 Hepatitis Type C 70.51 Where?

Personal Medical History Continued: Condition Code Current Past Comments Hepatitis Other 70.59 High Blood Pressure 401.9 High Cholesterol 272 Hip Fracture 820.8 Irritable Bowel Syndrome 564.1 Kidney Disease / Failure 586 Kidney Stones 592 Liver Disease 573.9 Migraine Headaches 346.9 Osteoporosis 733 Pneumonia 486 Prostate (enlargement) 600 Prostate (nodules) 600.1 Seizure / Epilepsy 780.39 Skin Condition (Eczema) 692.9 Skin Condition (Psoriasis) 696.1 Skin Condition (Abnormal Moles) 238.2 Sleep Apnea 780.57 Stomach Ulcer 531.9 Stroke 434.91 Thyroid (Nodule) 241 Thyroid High (Overactive) / Hyperthyroidism 242.9 Thyroid Low (Underactive) / Hypothyroidism 244.9 Surgical Procedure Code Yes Year Comments Abdominal Surgery Appendectomy (appendix removal) Back Surgery (lumbar) Biopsy (location) Breast Biopsy Breast Surgery Colonoscopy Coronary Bypass Coronary Stent EGD (Stomach Endoscopy) Cataract Gallbladder Removal Circle: Laparoscopic Heart Surgery (other than coronary bypass) Surgical Procedures Code Yes Year Comments

Mother Father Sister(s) Brother(s) Mom s Mom Mom s Dad Dad s Mom Dad s Dad Continued Hip Surgery Hysterectomy (total, including ovaries) Hysterectomy (partial, ovaries left) Knee Surgery LEEP (Cervix Surgery) Neck Surgery Ovary Ligation ( Tubal ) Ovary Removal Vasectomy Sigmoidscopy Sinus Surgery Circle: Laparoscopic Vaginal Abdominal Circle: Laparoscopic Vaginal Abdominal Adopted Yes No (Please Circle) If yes and you do not know your family history skip this section and continue to page 5 (Other Health Issues) FAMILY HISTORY Indicate which relative has had the following diseases (parents and siblings are most important). Disease No significant history known Alcoholism / Drug abuse Alzheimers Asthma Autoimmune Disease Bleeding or Clotting Disorder Cancer Breast Cancer Colon Cancer Other Type Cancer Ovarian Cancer Prostate Colon Polyp Coronary Artery Disease (e.g. heart attack, angina) Depression / Suicide / Anxiety Diabetes (childhood onset) Diabetes (adult onset) Other Relative Comments

Mother Father Sister(s) Brother(s) Mom s Mom Mom s Dad Dad s Mom Dad s Dad Disease Continued : Emphysema (COPD) Genetic Disorder (explain) Glaucoma Heart Disease (CHF) Heart Disease (Other) Hepatitis B or C High Blood Pressure - Hypertension High Cholesterol Hip Fracture Hypothyroidism / Thyroid Disease Kidney Disease Kidney Stones Macular Degeneration Migraine Headaches Osteoporosis Other Relative Comments OTHER HEALTH ISSUES: Tobacco Use Smoke cigarettes: Never No Yes Quit date: How many years did you smoke? Approximately how many packs a day did you smoke? Current smoker: Packs/day: # of years: Other tobacco: Pipe Cigar Snuff Chew Alcohol Use Do you drink alcohol? No Yes # of drinks/week: Drug Use Do you use marijuana or recreational drugs? No Yes Have you ever used needles to inject drugs? No Yes Exercise: Do you exercise regularly? Yes No What form of exercise? How long (minutes)? How often? Diet: How would you rate your diet? Good Fair Poor Would you like advice on your diet? No Yes Sexual Activity Sexually involved currently: No Yes Sexual partner(s) is/are/have been: male female Birth control method (circle below all that apply) None needed Condom, pill, diaphragm, IUD, vasectomy, other

Have you completed an Advance Directive or living will? No Yes Is violence at home a concern for you? No Yes Have you completed an Advance Directive? SOCIAL HISTORY: Occupation (or prior occupation): retired/unemployed/leave of absence/disabled (circle one if applicable) Employer: Years of education or highest degree: Marital status (circle one): single, partner, married, divorced, widowed, other: Spouse/partner s name: Number of children: Sports, hobbies: WOMEN S HEALTH HISTORY: Total number of pregnancies: Number of births: Date (month/day if known) of last menstrual period if you are still menstruating: Age at beginning of periods (menstruation): Age at end of periods (menopause): Thank you for taking the time to fill this out.

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback