Adult Health History for NEW Patients
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- Lewis Little
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1 Adult Health History for NEW Patients Name Date Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is a shorter update form you can use. Please fill in all five pages. If you cannot remember specific details, please provide your best guess. If you are uncomfortable with any question, do not answer it. Thank you! Main reason for today s visit: Other concerns: What are your health goals for the next year? Where were you getting your care before? In the past 2 weeks, have you been bothered by: Little interest or pleasure in doing things? Feeling down, depressed or hopeless? REVIEW OF SYMPTOMS: Please mark the box and/or circle any persistent symptoms you have had in the past few months. Read through every section and check no problems if none of the symptoms apply to you. List other concerns above. General Unexplained weight loss / gain Unexplained fatigue / weakness Fall asleep during day when sitting Fever, chills Skin New or change in mole Rash / itching Breast Breast lump / pain / nipple discharge Ears/Nose/Throat Nosebleeds, trouble swallowing Frequent sore throat, hoarseness Hearing loss / ringing in ears Eyes Change in vision / eye pain / redness Cardiovascular Chest pain / discomfort Palpitations (fast or irregular heartbeat) Respiratory Cough / wheeze Loud snoring / altered breathing during sleep Short of breath with exertion Gastrointestinal Heartburn / reflux / indigestion Blood or change in bowel movement Constipation Genitourinary Leaking urine Blood in urine Nighttime urination or increased frequency Discharge: penis or vagina Concern with sexual function Musculoskeletal Neck pain Back pain Muscle / joint pain Endocrine Heat or cold sensitivity Hematologic/Lymphatic Swollen glands Easy bruising Neurological Headache Memory loss Fainting Dizziness Numbness / tingling Unsteady gait Frequent falls Allergic/Immune Hay fever / allergies Frequent infections Psychiatric Anxiety / stress / irritability Sleep problem Lack of concentration Women only Pre-menstrual symptoms (bloating cramps, irritability) Problem with menstrual periods Hot flashes / night sweats 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 Revised 3/10/11 Page 1 of 5
2 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? Sigmoidoscopy or Colonoscopy (circle one) Date Polyp? Women only: Mammogram Date Abnormal? Pap Smear Date Abnormal? Bone Density Test Date Abnormal? PERSONAL MEDICAL HISTORY: Do you have now (current) or have you had (past) any of the following conditions? Condition Code Current Past Comments Alcohol / Drug abuse / Allergy (Hay Fever) Anemia Anxiety Arthritis (Rheumatoid) Arthritis (Osteoarthritis) Asthma Bladder / Kidney Problems Blood Clot (leg) Blood Clot (lung) Blood Transfusion V58.2 Breast Lump (benign) Cancer Breast Cancer Colon Cancer Other Type Cancer Ovarian Cancer Prostate 185 Cataracts Chicken Pox Colon Polyp Coronary Artery Disease Depression 311 Diabetes (adult onset) Diabetes (childhood onset) Diverticulosis Emphysema Fractures (broken bones) Where? Gallbladder Disease Gastroesophageal Reflux (Heartburn/GERD) Glaucoma NONE Revised 3/10/11 Page 2 of 5
3 PERSONAL MEDICAL HISTORY Continued: Condition Code Current Past Comments Gout Gynecological Conditions (Endometriosis) Gynecological Conditions (Fibroids) Gynecological Conditions (Other) Heart Attack Hepatitis Type A Hepatitis Type B Hepatitis Type C Hepatitis Other High Blood Pressure High Cholesterol Hip Fracture Irritable Bowel Syndrome Kidney Disease / Failure 586 Kidney Stones Liver Disease Migraine Headaches Osteoporosis Pneumonia 486 Prostate (enlargement) Prostate (nodules) Seizure / Epilepsy Skin Condition (Eczema) Skin Condition (Psoriasis) Skin Condition (Abnormal Moles) Sleep Apnea Stomach Ulcer Stroke Thyroid (Nodule) Thyroid High (Overactive) / Hyperthyroidism Thyroid Low (Underactive) / Hypothyroidism SURGICAL HISTORY Please check off any procedure or surgeries. List any abnormal finding or complications. NONE 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) Hip Surgery Hysterectomy (total, including ovaries) Circle: Laparoscopic Vaginal Abdominal Hysterectomy (partial, ovaries left) Circle: Laparoscopic Vaginal Abdominal Revised 3/10/11 Page 3 of 5
4 SURGICAL HISTORY Continued: Surgical Procedure Code Yes Year Comments Knee Surgery LEEP (Cervix Surgery) Neck Surgery Ovary Ligation ( Tubal ) Ovary Removal Vasectomy Sigmoidscopy Sinus Surgery Adopted Yes No (Please Circle) page 5 (Other Health Issues) If yes and you do not know your family history skip this section and continue to 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) 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 Mother Father Sister(s) Brother(s) Mom s Mom Mom s Dad Dad s Mom Dad s Dad Other Relative Comments Revised 3/10/11 Page 4 of 5
5 OTHER HEALTH ISSUES: Tobacco Use Smoke cigarettes: Never (If you never smoked please go to alcohol use question now) 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? # of drinks/week: Beer Wine Liquor Drug Use Do you use marijuana or recreational drugs? Have you ever used needles to inject drugs? Sexual Activity Sexually involved currently: Sexual partner(s) is/are/have been: male female Birth control method (circle below all that apply): None needed Condom, pill, diaphragm, vasectomy, other Exercise: Do you exercise regularly? What kind of exercise? How long (minutes)? How often? Diet: How would you rate your diet? Would you like advice on your diet? Good Fair Poor Safety: Do you use a bike helmet? No bike Do you use seatbelts consistently? Does your home have a working smoke detector? If you have guns in your home, are they locked up? Not applicable Is violence at home a concern for you? Have you completed an Advance Directive for Health Care (ADHC), Living Will, or POLST (Physician Orders for Life Sustaining Therapy)? (Circle above all that apply) SOCIAL HISTORY: Occupation (or prior occupation): retired/unemployed/leave of absence/disabled (circle one) Employer: Years of education or highest degree: Marital status (circle one): single, partner, married, divorced, widowed, other: Spouse/partner s name: Number of children: Ages if under 18 years: Number of grandchildren: Number of great grandchildren: Who lives at home with you? Leisure activities, group involvement, religion, volunteer work, recent travel: 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. Revised 3/10/11 Page 5 of 5
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