COMPREHENSIVE HEALTH HISTORY AND HEALTH RISK ASSESSMENT

COMPREHENSIVE HEALTH HISTORY AND HEALTH RISK ASSESSMENT Patient: Date: Provider: DOB: Adult Health History and Health Risk Assessment Your answers on this form will help your physician and care team get an accurate history of your medical concerns, conditions and risks Please fill in all pages. If you cannot remember specific dates, provide your best guess. If you are uncomfortable with any question do not answer it. We realize that the form will seem long. The information will, however help us better understand your health needs, so that, together, as your medical home develop the best possible treatment and care plans to maintain and improve your health. For Current Patients: Please update any information that is no longer current. If you find information that is incomplete or inaccurate please correct it. Main reason for today s visit: Other concerns: What are your health goals for the next year? Where were you getting your care before (if new patient)? What is your preferred language for English Spanish Other: health care? Where do you currently live? Live in an independent house, apartment, mobile home Live in an assisted living apartment, or board & Care. Name: Live in a nursing home. Name: Other (describe): What is your current living arrangement? (check each that applies) Live alone With spouse/significant other/domestic partner With child(ren) With other relatives(s) With non-relative(s) With paid caregiver Do you plan on changing your present living arrangements in the next 6 months? Yes No If yes, describe: Are you under the care of any Specialist, if yes Name and Specialty? Yes No Have you received care or had appointments with any other physicians or providers in last 3 months? If yes please list Name and specialties Yes No Have you been to the Emergency Room in the past 6 months? Yes No If Yes, How many times? Have you stayed overnight in a hospital in the past 12 months? Yes No If Yes, How many times? Have you been in a Skilled Nursing Facility in the past 12 months? Yes No If Yes, How many times?

In general, would you say your health is: (Check one answer) Excellent Very Good Good Fair Poor ADVANCED DIRECTIVES New Changes No Changes Yes No Have you completed a living will? Yes No Have you completed Advanced Directive or DNR (Do Not Resuscitate)? Yes No Have you completed a Health Care Power of Attorney Yes No Have you given copy of completed directives to us? Yes No Have you discussed your wishes with family? Yes No If you have not completed an Advanced Directive, are you interested in receiving more information? Name of Power of Attorney for Health Care: Relation: Contact #: REVIEW OF SYSTEMS: Please mark the box and/or circle any persistent symptoms you have had in the past few months. Read through ever section and check no problems if none of the symptoms apply to you. General Fever, Chills Unexplained weight loss/gain No problems Fall asleep during day when sitting Unexplained fatigue/weakness Respiratory Cough/wheeze Shortness of breath with exertion No problems Loud snoring/altered breathing during sleep Hematologic/Lymphatic Swollen Glands Easy Bruising No problems Skin Rash/itching Other: No problems Gastrointestinal Constipation Diarrhea Abdominal pain No problems Blood or change in bowel movement Heartburn/ reflux/ indigestion Neurological Headache Memory Loss Numbness/tingle No problems Fainting Dizziness Unsteady Gait Frequent falls Breast Breast lump Breast Pain Nipple discharge No problems Ears/Nose/Throat Nosebleeds Hoarseness Hearing loss No problems Trouble swallowing Ringing in ears Frequent sore throat Genitourinary Leaking urine Blood in urine Painful urination No problems Nighttime urination or increased frequency Frequent UTIs (> 3/yr) Discharge: penis or vagina Concern with sexual function Allergic/Immune Hay fever Allergies Frequent infection No problems Eyes Vision change Eye Pain Eye Redness No problems Psychiatric Anxiety Stress Irritability No problems Sleep Problem Lack of concentration Cardiovascular Chest Pain Palpitation (fast or irregular heartbeat) No problems Nighttime shortness of breath Musculoskeletal Neck pain Back pain Muscle pain No problems Joint pain Describe: _ Endocrine Heat sensitivity Cold Sensitivity Night sweats No problems Women Only Hot flashes Night Sweats No problems

Pre-menstrual symptoms (bloat, cramp, irritability) Problem with menstrual periods 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): IMMUNIZATIONS: New Changes No Changes Yes No Tetanus (Td) Yes No Influenza Yes No Tetanus with Pertussis (Tdap) Yes No Hepatitis A Yes No Hepatitis B Yes No MMR Yes No Meningitis Yes No HPV Yes No Pneumovax Yes No Varicella (chicken Pox) shot or illness Yes No Zostavax (shingles) PREVENTATIVE AND SCREENING New Changes No Change If you have had any of the following preventative or screening tests provide your best estimate of the date and results. If you have not done a test state Not done in the date field. Lipid (cholesterol) Sigmoidoscopy or Colonoscopy (circle which one) Polyp? No Yes Women only: Mammogram Pap Smear Bone Density Test Men Only: PSA MEDICATIONS New Changes No Change TAKE NO MEDICATIONS Medication Dose (eg mg/pill) Times per day Do you take your medications as prescribed? Most of the time Some of the time Rarely or none of the time What prevents you from taking your medications? Cost Experiencing side effects? Other: Medications not effective ALLERGIES: (include all such as OTC meds, herbals, foods, etc) New Changes No change I HAVE NO KNOWN ALLERGIES Allergy Reaction

FAMILY HISTORY: Check if present. And describe with as much detail as known, which family members and what side of family New Changes No Changes No significant family history known Alcoholism/Drug abuse Alzheimers or Dementias Autoimmune Disease Bleeding or Clotting Disorder Cancer (explain as much as known) Depression/Suicide/Anxiety Diabetes (adult onset) Diabetes (childhood onset) Genetic Disorder (explain) Heart Attack-myocardial infarct Osteoporosis Other: Comments (describe) Heart Disease (CHF) Heart Disease (other) Hepatitis B or C HIV High Blood Pressure High Cholesterol Hip Fracture Hypothyroidism Kidney Disease Kidney Stones Migraine Headache SURGICAL HISTORY Check if you have had and enter approx. year New Changes No Changes No previous surgeries Abdominal Surgery Appendectomy Back Surgery (lumbar) Biopsy (location) Breast Biopsy Rt Lt Both Breast Surgery Rt Lt B Coronary Bypass Coronary Stent Cataract Rt Lt Both Gallbladder Removal Heart Surgery (other) Hip Surgery Rt Lt Both Hysterectomy (uterus) Oophorectomy (ovaries) Knee Surgery Rt Lt Both LEEP(Cervix Surgery) Neck Surgery Tubal Ligation Vasectomy Ovary Removal Rt Lt B Sinus Surgery Other: List YEAR COMMENTS PAST MEDICAL HISTORY New Changes No Changes No Known Medical Illness Condition Code Comment Diabetes (Adult onset) 250.00 If you have Diabetes have you had an diabetic eye Diabetes (Childhood) 250.01 exam done in the past year? Yes No Eye Doctor Name: High Blood Pressure 401.9 Smoking 305.1 High Cholesterol 272.0 GERD (reflux) 530.81 Heart Attack, Angina 414.00 Depression 311

Chronic Anticoagulation V58.61 Emphysema (COPD) 492.88 Irritable Bowel 564.1 Osteoporosis 733.00 Syndrome Alcohol/Drug Abuse Allergy (Hay Fever) Anemia Anxiety Arthritis (rheumatoid) Arthritis (Osteoarthritis) Asthma Bladder/Kidney Problems Blood Clot (leg) Blood Clot (lung) Blood Transfusion Breast Lump (benign) Cancer Breast Cancer Colon Cancer Ovarian Cancer Prostate Cancer Other: Cataracts Chicken Pox Cirrhosis Colon Polyp Diverticulosis Fractures (broken Bones) Gallbladder Disease Glaucoma Gout Gout GYN (Endometriosis GYN (Fibroids) GYN Other Hepatitis A Hepatitis B Hepatitis C HIV Kidney Disease/Failure Frequent UTI (>3/yr) Kidney Stones Liver Disease Migraine Headaches Pneumonia Prostate Enlargement Seizure/Epilepsy Skin (Eczema) Skin (Psoriasis) Skin (Abnormal Moles) Sleep Apnea Stomach Ulcer Stroke Thyroid (Nodule) Thyroid Overactive Thyroid Underactive Other: (list) Other: (list) OTHER HEALTH ISSUES: Tobacco Use Exercise: Do you exercise regularly? Yes No Smoke Cigarettes? Never No Yes What Kind of exercise? (If you have never smoked please go to alcohol use question) How long (minutes)? How often? Quit Date: How many years did you smoke? Diet Approx how many packs a day did you smoke? How would you rate your diet? Good Fair Current smoker Packs/day: # of years Poor Other Tobacco: Pipe Cigar Snuff Chew Would you like advice on your diet? Yes No Alcohol Use Safety Do you drink alcohol? No Yes Do you use a bike helmet? Yes No # of drinks/week: Beer Liquor Wine No bike Drug Use Do you use seatbelts consistently? Yes No Do you use marijuana or No Yes Does your home have a working smoke Yes No recreational drugs? detector? Have you ever used needles to No Yes If you have guns in your home, are they Yes No inject drugs? locked up? Not Applicable Sexual Activity Is violence at home a concern for you? Yes No Sexually Involved Currently: No Yes Within the last year have you been Yes No humiliated or emotionally abused in other ways by your partner or ex-partner? Sexual partners(s) is/are/were Male Female Within the last year, have you been afraid of your partner or ex-partner? Birth control method (circle which) None needed Within the last year, have you been raped Condom pill, diaphragm, vasectomy. Other: or forced to have any kind of sexual activity by your partner or ex-partner? Within the last year, have you been kicked, hit, slapped or otherwise physically hurt by your partner or ex-partner? Yes Yes Yes No No No

Over the past 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things 2. Feeling down, depressed or hopeless 3. Trouble falling asleep, staying asleep, or sleeping to much 4 Feeling tired or having little energy 5. Poor appetite or over eating 6. Feeling bad about yourself-or that you re a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed. Or, the opposite-being so fidgety or restless that you have been moving around more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way Not at all Several Days More Than Half the Days Nearly Every Day 10. If you checked off any problems, how difficult have those problems made it for you to do your work, take care of things at home or get along with other people? (circle) Not difficult at all Somewhat difficult Very difficult Do you have current on ongoing pain? Yes No (if yes please complete the following, if no go to next section) Where is your pain? Describe your pain? What relieves your pain? How do you feel abut taking pain medications? Present pain medication (list): Present pain medication effectiveness? What are your pain control goals? Sleep Comfortably Comfort at rest Comfort with movement Stay Alert Be able to work Other: Extremely difficult Do you use any of the following special equipment because of a disability or health problem? Are you currently receiving any of the following services from an agency? Yes No If you would benefit from please circle Yes No If you would benefit from please circle Walker Home Health Nurse Bedside Commode Physical, Occupational, Speech Tx at home Wheelchair Home Health Aide Hoyer Lift Social Worker Cane Adult Day Care Center Grab Bars Assistance with Transportation Bath Bench Other: Hospital Bed Do you currently use or receive any of the following? Ramps Raised Toilet Seat Yes No Hearing Aids Feeding Tube Other: Oxygen Dose and When? Are you currently being treated for any of the following health conditions? For yes, please describe Colostomy Care Catheter Care Other: Yes No For each of the activities, indicate whether: you are able Dialysis to do this without help or need some help performing activity: Memory loss NO HELP NEEDED

Arthritis Urinary Problems Need some Help Able to do Breathing Problems Using the toilet Cancer Bathing Circulation Problems Dressing Osteoporosis Eating Stomach/Bowel Problems Getting in/out of bed or chairs Recent Fracture (last 12 months) Walking Parkinson s Managing Money Ankle/Leg Swelling Taking Medications Uncorrected Hearing Loss Preparing Meals Other: Shopping and Errands Other: Housekeeping Chores Using the Telephone If you receive help with any of the activities selected Do you need help at home because of health problems and are unable to get help? above, who is the helper?(name, relationship and phone number if we may contact you helper? Yes No Name: Relationship: # Which of the following statements fits you best in terms of health? Check all that apply. Must stay in bed all or most of the time because of physical limitations Must stay in the house all or most of the time because of physical limitations Need the help of another person in getting around inside or outside the house Need the help of some special aid like a cane/wheelchair to get around inside or outside the house Do not need the help of another person or a special aid but have trouble getting around freely Not limited in any of these ways Yes No Have you fallen 2 or more times in the last year? Yes No Are you afraid of falling? Yes No Do you frequently feel dizzy when standing? Yes No Does your home have rugs in the hallway, lack grab bars in the bathroom, lack handrails on the stairs or have poor lighting? (circle those that apply) Yes No Do have stairs to get into your home? Yes No Do have stairs to get to your bedroom or bathroom? THANK YOU for Completing this HEALTH QUESTIONAIRE. It will be valuable to us as we continue to strive to improve the care we provide to our patients. Ver: 03/13