6. Do you have an Advance Directive or Living Will? Yes No These are written statements about how you want to be treated if you get very sick.
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1 Adult Health History Name: First Last Name you like to be called: Today s Date: Date of Birth: Male Female Transgender Male to Female Transgender Female to Male Other 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, the clinic staff will help you. GENERAL 1. Are you Single Married Partnered Divorced or Separated Widowed 2. Where did you grow up? 3. What kind of work do you do or, if retired, did you do? 4. What level of education did you complete? 5. When was the last time you were seen by a primary care doctor? Who did you see? 6. Do you have an Advance Directive or Living Will? Yes No These are written statements about how you want to be treated if you get very sick. 7. Do you have a POLST (Physician Order for Life Sustaining Treatment)? Yes No Please bring Advance Directive, Living Will, and/or POLST to your appointment. continued on next page Page 1
2 ALLERGIES 8. Have you ever had any allergic reaction (bad effect) to a medicine or a shot? No, I am not allergic to any medicines or shots. Yes. Please write the name of the medicine or shot and the effect you had below. Medicine I am allergic to Example: Atenolol What happens when I take that medicine I get a rash 9. Do you get an allergic reaction (bad effect) from any of the following? No, I have no allergies that I know of. Yes. Check all that apply Allergic to Latex (rubber gloves) Grass or Pollen Eggs Shellfish What happens continued on next page Page 2
3 MEDICINES 10. Are you taking any prescription medicines? I do not take any prescription medicines. Yes. List your medicines below OR I brought my pill bottles or a list. Pharmacy: Name of medicine Strength or Amount How many pills or doses do you take at a time? Example: Furosemide 20 mg 2 morning 2 noon dinner bed 11. What over-the-counter drugs, vitamins and nutritional supplements do you take regularly? No, I do not take any over-the-counter drugs, vitamins or nutritional supplements. Yes. Check all that apply and enter Strength or Amount for those you are taking. Name of medicine Pain Reliever (examples: Tylenol, Advil, Motrin, Aleve, Aspirin) Vitamins Antacid (examples: Tums, Prilosec) Herbal medicine, please list: Nutritional supplements, please list: Other, please list: Strength or Amount continued on next page Page 3
4 MEDICAL HISTORY 12. Have you ever had any of the following health problems? Check all that apply Abnormal pap (not normal pap test) Allergies Anemia (low iron, low blood count) Anxiety Arthritis Asthma (breathing disease) Blood transfusion Cancer Cataracts Congestive heart failure (CHF) Bowel disorder Clotting disorder Chronic obstructive pulm disease Depression (feeling down or blue) Diabetes (high blood sugar) Emphysema (lung disease) GERD (heartburn, acid reflux) Glaucoma (eye disease) Gout (joint pain in toes) Headaches Hearing Loss Heart Attack Hepatitis (disease that affects the liver) High Blood Pressure High Cholesterol (fat found in the blood) HIV/AIDS Jaundice (skin and eyes turn yellow) Kidney Disease Kidney Stones Liver Disease Meningitis Osteoporosis (weak bones) Prostate Problems Seizures Sexually Transmitted Disease Shingles (painful skin rash) Sickle Cell (disorder affecting red blood cells) Skin Problems Stroke Substance Abuse (illegal drugs, drug problem) Thyroid Disease Tuberculosis (TB, lung disease) Ulcers (open sores) Urinary Problems (problems peeing) Heart Murmur (extra noise heart makes) Other problems: continued on next page Page 4
5 SURGICAL HISTORY 13. Have you ever had surgery? No, I have never had surgery Yes. Please list each surgery below. Surgery When FAMILY HISTORY 14. Have any of your family members ever had any of the following health problems? Check all that apply Mother Alive Passed Away Father Alive Passed Away Sisters # sisters: Brothers # brothers: continued on next page Page 5
6 SOCIAL HISTORY Do you drink alcohol? No Yes, please answer the questions below: Wine (glasses a week) How many years? Date Quit? Beer (cans a week) How many years? Date Quit? Liquor (shots a week) How many years? Date Quit? 16. Do you use drugs? No Yes, please answer the questions below: Used within the last week? No Yes, how many times Types of drugs used: check all that apply Marijuana Methamphetamines Cocaine Heroin 17. Have you ever smoked cigarettes, cigars, smoked a pipe, used snuff, or chewed tobacco? No Yes, please answer the questions below: Cigarette (packs a day): How many years? Date Quit? Cigar (number a day): How many years? Date Quit? Pipe (number a day): How many years? Date Quit? Snuff (number a day): How many years? Date Quit? Chew (number a day): How many years? Date Quit? Do you want to quit? No Yes Already quit 18. Do you have sex with Men Women Both I don t have sex If you use birth control, what type do you use? Abstinence (no sex) Check all that apply Coitus Interruptus (withdrawal or pullout method) Condom Diaphragm Implant Injection Inserts IUD Birth Control Pills Patch Post-menopausal Rhythm (calendar tracking) Spermicide Sponge Tubal Ligation (tubes tied) Other Vasectomy (male surgery for birth control) 19. Exercise. Do you exercise 2 or more days a week? No Yes continued on next page Page 6
7 IMMUNIZATIONS (Shots) Have you had any of the following shots? Flu Year Where given Tetanus Diptheria (Td) Year Where given Tetanus-Diptheria-Pertusis (Tdap) Year Where given HPV (Gardasil) Year Where given Pneumovax (pneumonia) Year Where given Zostavax (shingles) Year Where given Hepatitis A Year Where given Hepatitis B Year Where given MMR Year Where given SPECIALTY SERVICES Are you currently seeing any other doctors? Anything else we should know? HLA-5, 4/7/2015 Page 7
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