Review of Systems. Eye/Ear/Nose/Throat. hard to empty bladder. palpitations/irregular heartbeat. persistent cough, wheezing. feelings of depression

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1 Name: Review of Systems DOB: / / For staff: place patient label here. Check here if no symptoms. Check concerns below only if you have experienced symptoms recently. General loss of appetite abnormal weight gain abnormal weight loss night sweats fatigue Eye/Ear/Nose/Throat Vision changes Ringing in ears difficulty hearing nasal congestion difficulty swallowing Cardiovascular chest pain palpitations/irregular heartbeat fainting/blackouts leg swelling Respiratory persistent cough, wheezing shortness of breath coughing up blood Gastrointestinal reflux abdominal pain chronic constipation chronic diarrhea nausea/vomiting blood in stool Hematologic/Skin abnormal bleeding/bruising mole changes rash Urologic frequent urination painful urination blood in urine bladder leakage hard to empty bladder Genital abnl menstrual bleeding painful periods sexual difficulty breast lump/discharge vaginal/penile discharge Neurological headache dizziness localized weakness memory loss Musculoskeletal back pain joint pain frequent falls Psychiatric feelings of depression apathy/disinterest nervous/anxious irritable sleeping problems excessive thirst Endocrinologic heat/cold intolerance excessive sweating hair loss

2 Pharmacy Ask us about MyADC. Name: DOB: / / For staff: place patient label here. ADC Family Practice New Adult Patient/Annual Form Reason for your visit Past Medical History: Please review the below list, and check any problems that you have had now or in the past. Abnormal Pap Smear Drug Abuse Osteoarthritis Acne Emphysema Osteopenia Adult ADD Eczema Osteoporosis Alcohol abuse Frequent Urinary Tract Infection Positive TB skin test Anemia Frequent Sinus Infections Prostate problems Anorexia Gallstones Psoriasis Anxiety disorder Gout Reflux (heartburn) Asthma Glaucoma Rheumatoid Arthritis Atrial Fibrillation Heart Attack Rosacea Bipolar disorder Heart Disease Seasonal Allergies Blood clot Hepatitis Seizures Blood Transfusion High Blood Pressure Sexually transmitted disease Breast Cancer High cholesterol Which One: Chronic Bronchitis Irritable Bowel Syndrome Stroke Crohn s disease Kidney Stones Tuberculosis Colon Polyps Kidney disease Thyroid disease/cancer Congestive Heart Failure Kidney Infections Stomach Ulcers Depression Lupus Ulcerative Colitis Diabetes Melanoma or other skin Cancer Valve problem/murmur Diverticulosis Migraines Other Current Medications: Please include over-the-counter medications and food supplements Drug Name: Dose: How Often? Drug Name: Dose: How Often? Are You Allergic to any medications? Yes No Drug Name: Type of Reaction Drug Name: Type of Reaction 2

3 Reproductive History: 1. Are you sexually active: Yes No 2. Number of sexual partners: (in the past year) (in the last 5 years) 3. Sexual preference (check one): male female both 4. Type of birth control (check all that apply): pills patch ring implant under skin spermacide Depoprovera IUD tubal ligation vasectomy natural family planning condoms For women only: 1st day of last menstrual period Age of first period Age of menopause # of pregnancies # of live births # of miscarriages Last abnormal pap (year) # of abortions If you had an abnormal pap did you have a colposcopy? Yes No Did you have treatment (cryo, laser, LEEP, cone biopsy)? Yes No Surgical History: Have you had surgery in the past? Yes No If yes, please check or list: Type of surgery: Year Type of surgery: Year Appendectomy Arthroscopy (Joint) Back Surgery Bypass surgery (Heart) Cataract Surgery Cesarean section Gallbladder removal Hemorrhoids Hernia Hip Replacement Hysterectomy Knee Replacement LEEP/LOOP (cervix) Mastectomy/lumpectomy Neck surgery Polyp removal Tonsillectomy Vasectomy/Tubal ligation Plastic Surgery Other: Any hospitalizations (other than births and surgeries)? Yes No If yes, please explain: Family History: (grandparents, brothers, sisters, parents, aunts, uncles, children) Have any of your family members had any of the following problems? Condition Family member and age of onset? Condition Breast Cancer Depression/Anxiety Colon Cancer Other mental issues Prostate Cancer Alcohol/drug problems Ovarian Cancer High cholesterol Melanoma Blood clotting disorder Heart Disease/Attack Osteoporosis Stroke Rheumatoid Arthritis Diabetes Lupus High Blood Pressure Ulcerative Colitis Thyroid Disease Crohn s Colitis Family member Any other illness in the family not listed: Has anyone in your immediate family died before the age of 50? Yes No 3

4 Social History: Social System: Marital status (check one):single divorced separated married widowed Number of children (include names and ages): List all household members Highest level of education reached Occupation Yes No 1. Do you have adequate family or community support? Yes No 2. Do you have any concerns for your safety (emotional, physical, sexual abuse)? Nutrition & Exercise Yes No 1. Do you follow a specific diet (vegetarian, vegan, gluten-free)? 2. How many servings of dairy or calcium rich foods do you eat per day Yes No 3. Do you take a calcium supplement? Yes No 4. Do you take a multi-vitamin? Yes No 5. Do you skip meals often? 6. How many meals per week are take-out/dine-out? Yes No 7. Do you exercise? If so, what type and how often? Yes No 8. Would you like more information on weight loss strategies? Healthy Habits Smoking history: Never Current Past (Quit date ) 1. What type? Cigarettes E-cigarettes Cigars Pipes Chewing tobacco 2. How much do/did you smoke (#/day)? / 3. How many years have you smoked in total? Yes No 4. Are you interested in quitting? Yes No 5. Any smoker in your household? Yes No 6. Do you drink caffeine? If so, how much? Yes No 7. Have you ever used street drugs? 8. Which ones? IV marijuana amphetamines cocaine heroin downers inhalants Yes No 9. Are you still using? Which ones? Yes No 10. Do you drink alcohol? Drink of choice? If so, how many times? per week OR per month OR per year How many drinks at one time? Yes No 11. Have you ever had a problem with alcohol (legal, financial, social, personal or work related)? If yes, please explain? Yes No 12. Do you wear a seat belt? Yes No 13. Do you wear a helmet? Yes No 14. Do you wear sunscreen? Yes No 15. Is there a gun in your home? Yes No 16. Do you have a living will? Yes No If so, is it locked and unloaded? Yes No Would you like more info? 4

5 Health Maintenance: Have you ever had the following: Cholesterol screening? Yes No Results: Diabetes screening? Yes No Results: Prostate screening (PSA)? Yes No Results: Pneumonia Vaccine? Yes No When? Flu shot? Yes No When? Tetanus/Pertussis shot? Yes No What year? Hepatitis B Vaccine? Yes No Did you complete the series? Yes No Human Papilloma (Gardasil) Vaccine? Yes No Did you complete the series? Yes No Shingles Vaccine? Yes No When? Colon Cancer screen? Yes No (colonoscopy, flexible sigmoidoscopy) What year? Results? Bone Density? Yes No Date: / / Results: Mammogram? Yes No Date: / / Results: Pap Smear? Yes No Date: / / Results: 5