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Name (First, Middle, Last):
_________________________________________________________
_________________________________________________________
_________________________________________________________
Today's Date: ___________________________________
Date of Birth: ___________________________________
Address:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Telephone Number (home) (______)___________________________________
(cell) (______)____________________________________
(work) (______)___________________________________
Filling out this form
- Answering these questions will help your doctor understand your health and how best to treat you.
- If you need help filling out this form:
-
Bring this form with you to your appointment and a nurse will help you.
OR
- Call the clinic at [555-1212 ext. 123] before your appointment and someone can help you over the phone.
-
Bring to your appointment:
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We look forward to working with you!
General Health
1.Why did you make this appointment? (Check all that apply.)
___ regular checkup
___ first appointment to start care with a new doctor
___ switching doctors (from whom: __________________________________________________________________________________________________)
___ have a specific health problem (if so, explain __________________________________________________________________________________________________)
2. In general, what do you consider to be your main health problem(s)? (Check all that apply.)
___ heart problems
___ diabetes
___ stomach problems
___ depression/emotional problems
___ ear, nose, or throat problems
___ joint problems
___ high blood pressure
___ other(s)—please explain:
_________________________________________________________
_________________________________________________________
_________________________________________________________
3. How would you describe your health?
___ Excellent ___ Very Good ___ Good ___ Fair ___ Poor
4. Are you taking any prescription medicines?
___ Yes. Please list your medicines below OR ___ I brought my pill bottles or a list.
___ No, I do not take any prescription medicines. (If no, go to question #5.)
Name of medicine | Amount/ size of pill | How many pills or doses do you take at |
---|---|---|
Example: Furosemide |
20 mg | 2 morning 2 noon ___ dinner ___ bed |
___ morning ___ noon ___ dinner ___ bed | ||
___ morning ___ noon ___ dinner ___ bed | ||
___ morning ___ noon ___ dinner ___ bed | ||
___ morning ___ noon ___ dinner ___ bed | ||
___ morning ___ noon ___ dinner ___ bed | ||
___ morning ___ noon ___ dinner ___ bed |
(Please use the back of this form if you have more prescription medicines.)
5. What over-the-counter medicines, do you take regularly?
___ Pain reliever (for example: Tylenol, Advil, Motrin, Aleve, aspirin)
___ Vitamins
___ Antacid (for example: Tums, Prilosec)
___ Herbal medicine (please list) ________________________________________________________________________
___ Other (please list) __________________________________________________________________________________
___ None—I do not take any over-the-counter medicines regularly.
6. Have you ever had any allergic reaction (bad effects) to a medicine or a shot?
___ Yes. (Please write the name of the medicine and the effect you had.)
___ No, I am not allergic to any medicines.
Medicine I am allergic to | What happens when I take that medicine |
---|---|
Example: Atenolol |
I get a rash |
7. Do you get an allergic reaction (bad effect) from any of the following? (Check all that apply)
___ latex (rubber gloves)
___ grass or pollen
___ eggs
___ shellfish
___ Other (please describe) _________________________________________________________________________
___ No—I have no allergies that I know of.
8. Have you ever been a patient in a hospital overnight?
___ Yes. (If yes, explain EACH reason and when.)
___ No, I have never been a patient in a hospital. (If no, go to question #9)
I was in the hospital because: | When |
---|---|
Example: Heart attack |
6 years ago |
9. Have you ever had a colonoscopy (a test to look at your insides by sending a camera through your bottom) ___ Yes ___ No
When ____________________________________________________________
10. Have you ever received a blood transfusion (when you are given extra blood)? ___ Yes ___ No
When ____________________________________________________________
For Women Only
11. Have you ever been pregnant? ___ Yes ___ No
How many times?___________________________________________________________________________
How many children have you given birth to?______________________________________________
12. Have you had a PAP smear? ___ Yes ___ No
Date of last one ___________________________________________________________________________
13. Have you ever had a PAP smear that was not normal? ___ Yes ___ No
14. Have you had a mammogram (breast x-ray)? ___ Yes ___ No
Date of last one___________________________________________________________________________
Shots
15. When was your last Tetanus shot? Year_______________ ___ never ___ don’t know
16. When was your last Pneumonia shot? Year_______________ ___ never ___ don’t know
17. When was your last Flu shot? Year_______________ ___ never ___ don’t know
Social History
18. Circle the highest grade you finished in school?
Grade School 1 2 3 4 5 6 7 8 High School 9 10 11 12 GED Vocational School 1 2 3 College 1 2 3 4+
19. What language do you prefer to speak? ___ English ___ Spanish ___ Other ____________________________________
20. How well can you read?
___ Very well ___ Well ___ Not well ___ I can not read
21. What do you do during the day?
___ Work full-time
___ Work part-time
___ Attend school
___ Take care of children at home
___ Go out most days (shop, visit, appointments)
___ Stay home most days
___ Other ____________________________________________________________
22. Have you ever smoked cigarettes, cigars, used snuff, or chewed tobacco?
___ No (if no, go to question #23.)
___ Yes
a. When did you start? ____________________________________________________________
b. How much per week? ____________________________________________________________
c. Have you quit? ___ No ___ Yes, when ____________________________________________________________
d. Do you want to quit? ___ No ___ Yes ___ Already Quit
23. Do you drink alcohol?
___ No (if no, go to question #24.)
___ Yes
a. Have you ever felt you ought to cut down on your drinking? ___ Yes ___ No
b. Have people ever annoyed you by criticizing your drinking? ___ Yes ___ No
c. Have you ever felt bad or guilty about your drinking? ___ Yes ___ No
d. Have you ever had a drink first thing in the morning? .___ Yes ___ No
24. Are you ___ Single ___ Married ___ Partnered ___ Divorced or Separated ___ Widowed?
25. Who lives in your house?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
26. Do you have sex with ___ men ___ women ___ both ___ neither
27. Do you have any beliefs or practices from your religion, culture, or otherwise that your doctor should know? For example:
___ I do not accept blood/blood products because of personal or religious beliefs.
___ I do not use birth control because of personal or religious beliefs.
___ I fast (go without food) for periods of time for personal or religious reasons.
___ I do not eat meat.
___ I do not eat anything that comes from an animal.
___ Other special diets or eating habits. (Please describe.) ____________________________________________________________
___ I use traditional medicines or treatments, such as acupuncture or herbs.
___ Other beliefs ____________________________________________________________
___ No, I have no specific beliefs or practices that change the course of my health care.
28. Check any of the following things you use to help you walk.
___ Cane ___ Walker ___ Wheelchair
___ Other ____________________________________________________________
___ I do not need any help walking
29. Check any of the following types of help at home you receive (paid help or family and friends).
___ Help with cleaning/laundry.
___ Help with shopping.
___ Help with personal care (bathing, dressing).
___ Help with taking my medicines.
___ I do not use any help at home.
30. In the past year, have you been emotionally or physically abused by your partner or someone important to you? ___ Yes ___ No
31. In the past year have you been hit, pushed, shoved, kicked or threatened by a partner or someone important to you? ___ Yes ___ No
Exercise
Describe what kind of exercise you do. (Check all that apply.) | How many times per week do you exercise? | For how long do you exercise each day? |
---|---|---|
___ walking ___ biking ___ swimming ___ weight training ___ yoga ___ other_______________ ___ I do not exercise |
___ once per week ___ twice per week ___ 3 times a week ___ 4 times a week ___ 5 times a week ___ 6 times a week ___ 7 times a week or more |
___ less than 15 minutes ___ 15-30 minutes ___ 30 – 45 minutes ___ 45 minutes – 1 hour ___ over 1 hour |
Comments:
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Family History
What medical problems do people in your family have?
Family Member | Medical Problems |
---|---|
Mother: | ___ Diabetes (sugar) ___ High blood pressure ___ Heart problems ___ Cancer ___ Other: __________________________________________ |
Father: | ___ Diabetes (sugar) ___ High blood pressure ___ Heart problems ___ Cancer ___ Other: __________________________________________ |
Sisters: | ___ Diabetes (sugar) ___ High blood pressure ___ Heart problems ___ Cancer ___ Other: __________________________________________ |
Brothers: | ___ Diabetes (sugar) ___ High blood pressure ___ Heart problems ___ Cancer ___ Other: __________________________________________ |
History of Medical Conditions
Have you ever had any of the following conditions? (Check all that apply)
___ Anemia (low iron blood) ___ Asthma (wheezing) ___ Diabetes (sugar)
___ Heart Trouble ___ Hemorrhoids (piles) ___ Cancer
___ Hepatitis (yellow jaundice) ___ Tuberculosis (TB) ___ Liver Trouble
___ Pneumonia ___ Rheumatic fever ___ Ulcers
___ Stroke ___ High Blood Pressure
___ Skin problems ___ Depression (feeling down or blue)
___ Epilepsy (fits, seizures) ___ Anxiety (nerves, panic attacks)
___ VD, STD (syphilis, gonorrhea, chlamydia, HIV)
___ Other_____________________________________________
Review of Symptoms
Yes | No | ||
---|---|---|---|
Sleeping | Do you feel tired a lot? | ___ Yes | ___ No |
Do you have trouble falling or staying asleep? | ___ Yes | ___ No | |
Do you have other problems with sleep? | ___ Yes | ___ No | |
Eating | Have you lost your appetite recently? | ___ Yes | ___ No |
Have you lost weight in the last year without trying? | ___ Yes | ___ No | |
Do you eat too much or have you gained weight recently? | ___ Yes | ___ No | |
Do you have other problems with eating? | ___ Yes | ___ No | |
Throat | Do you have sore throats a lot? | ___ Yes | ___ No |
Do you have other problems with your throat? | ___ Yes | ___ No | |
Ears | Do you have trouble hearing? | ___ Yes | ___ No |
Do you wear a hearing aid? | ___ Yes | ___ No | |
Do you have constant ringing or noises in your ears? | ___ Yes | ___ No | |
Do you have other problems with your ears? | ___ Yes | ___ No | |
Back | Do you have back pain? | ___ Yes | ___ No |
Do you have any other problems with your back? | ___ Yes | ___ No | |
Eyes | Do you have trouble with your vision or seeing? | ___ Yes | ___ No |
Do you wear glasses or contacts? | ___ Yes | ___ No | |
Do you have other problems with your eyes? | ___ Yes | ___ No | |
Nose and Sinuses | Do you have a runny or stopped up nose a lot? | ___ Yes | ___ No |
Do you have other problems with your nose or sinuses? | ___ Yes | ___ No | |
Teeth and Mouth | Do you have sore or bleeding gums? | ___ Yes | ___ No |
Do you wear plates or false teeth? | ___ Yes | ___ No | |
Do you have other problems with your teeth and mouth? | ___ Yes | ___ No | |
Heart or Breathing | Do you ever have pain/tightness in your chest when working or exercising? | ___ Yes | ___ No |
Do you wake up at night with trouble breathing? | ___ Yes | ___ No | |
Do you have a racing or skipping heartbeat at times? | ___ Yes | ___ No | |
Do you have other heart or breathing problems? | ___ Yes | ___ No | |
Bowel Movements | Do you have bowel movements (poop) that are black, like tar, or bloody? | ___ Yes | ___ No |
Do you have any other problems with your bowel movements (poop)? | ___ Yes | ___ No | |
Peeing and Kidney Stones | Do you have trouble passing your urine (peeing)? | ___ Yes | ___ No |
Does it burn when you pass urine (pee)? | ___ Yes | ___ No | |
Do you have to pee more than 2 times a night? | ___ Yes | ___ No | |
Do you leak urine (pee)? | ___ Yes | ___ No | |
Have you ever passed kidney stones? | ___ Yes | ___ No | |
Do you have any other problems with your peeing? | ___ Yes | ___ No | |
Joints | Do you have swollen or painful joints? | ___ Yes | ___ No |
Do you have any other problems with your joints? | ___ Yes | ___ No | |
Head, Balance, Fever and Weakness | Do you have frequent or severe headaches? | ___ Yes | ___ No |
Have you ever fainted (passed out)? | ___ Yes | ___ No | |
Have you lost your balance and fallen recently? | ___ Yes | ___ No | |
Do you have weakness in any part of your body? | ___ Yes | ___ No | |
Have you had a fever within the past month? | ___ Yes | ___ No | |
Do you have any other problems with your head or balance? | ___ Yes | ___ No | |
Emotional Health | Do you get upset easily? | ___ Yes | ___ No |
Do frightening thoughts keep coming into your mind? | ___ Yes | ___ No | |
Have you ever been hospitalized for nerves, thoughts or moods? | ___ Yes | ___ No | |
During the past 2 weeks, have you often been bothered by having little interest or pleasure in doing things? | ___ Yes | ___ No | |
During the past 2 weeks, have you often been bothered by feeling down, depressed, or hopeless? | ___ Yes | ___ No | |
Do you have any other problems with your emotional health? | ___ Yes | ___ No | |
Men Only | Have you ever had prostate trouble? | ___ Yes | ___ No |
Do you have any other male problems? | ___ Yes | ___ No | |
Women Only | Do you have pain or lumps in your breast? | ___ Yes | ___ No |
Do you have unusual vaginal discharge or itching? | ___ Yes | ___ No | |
Do you or have you taken hormones (such as birth control pills)? | ___ Yes | ___ No | |
Do you have any other female problems? | ___ Yes | ___ No |