Health Information Form for Adults



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Transcription:

A. Identification B. Emergency Contacts Name (Last) (First) (Middle) Maiden Name In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Primary Alternate Relationship Home Work Home Work Cell E-mail Cell E-mail of Birth o Male o Female Height Weight Eye Color Hair Color In Case of Emergency, Notify: Secondary Contact Name (Last) (First) (Middle) Ethnicity/Race Birthmarks/Scars Relationship Blood / RH Type Special Conditions Marital Status Occupation Company Name Home Work Cell E-mail Number Languages Spoken Primary and Secondary Primary Health Insurance Carrier Policy Number In Case of Emergency, Notify: Medical Contact Physician (Indicate Specialty) Secondary Health Insurance Carrier Policy Number Dentist Pharmacy

C. h e a l t h c a r e p r o v i d e r s Healthcare Provider Speciality Primary Care Physician Emergency No. (after hours) o Yes o No Name E-mail Group or Association Web /URL Healthcare Provider Speciality Primary Care Physician Emergency No. (after hours) o Yes o No Name E-mail Group or Association Web /URL Healthcare Provider Speciality Primary Care Physician Emergency No. (after hours) o Yes o No Name E-mail Group or Association Web /URL Healthcare Provider Speciality Primary Care Physician Emergency No. (after hours) o Yes o No Name E-mail Group or Association Web /URL

D. insurance providers Insurance Provider Type E-mail Company Name Web /URL Primary Insured Person Name Social Security No. Employer Name Contact Name Identification Group Number Member (ID) Number Contact Information Emergency No. (after hours) Number Insurance Provider Type E-mail Company Name Web /URL Primary Insured Person Name Social Security No. Employer Name Contact Name Identification Group Number Member (ID) Number Contact Information Emergency No. (after hours) Number Insurance Provider Type E-mail Company Name Web /URL Primary Insured Person Name Social Security No. Employer Name Contact Name Identification Group Number Member (ID) Number Contact Information Emergency No. (after hours) Number

e. Legal Documents/Medical directives o Living Will o Durable Power of Attorney for Healthcare o Power of Attorney Document Location (Physical Location) Location Name (for example, Bank of America) Contact (Name of person who has access to the document) Contact Information Legal Representative (Name of person who you have assigned legal authority) Home Cell Pager E-mail Work Work E-mail Contact Information Home Cell Filed Pager Work E-mail E-mail Work Organ Donation Organ Donor p Yes p No State Where Registered o Living Will o Durable Power of Attorney for Healthcare o Power of Attorney Document Location (Physical Location) Location Name (for example, Bank of America) Contact (Name of person who has access to the document) Contact Information Legal Representative (Name of person who you have assigned legal authority) Home Cell Pager E-mail Work Work E-mail Contact Information Home Cell Filed Pager Work E-mail E-mail Work Organ Donation Organ Donor p Yes p No State Where Registered

F. medical history check appropriate o Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive o Arthritis o Asthma o Bronchitis o Cancer o Chlamydia o Diabetes o Dizziness o Emphysema o Epilepsy o Eye Problem o Fainting o Frequent or Severe Headache o Glaucoma o Gonorrhea o Hearing Impairment o Heart Condition o Hemodialysis o Herpes o High Blood Cholesterol of Onset o High Blood Pressure o Hypoglycemia o Jaundice o Kidney Disease o Low Blood Pressure o Mental Retardation o Pain or Pressure in Chest o Palpitations o Periods of Unconsciousness o Rheumatic Fever o Rheumatism o Seizures o Shortness of Breath o Stomach, Liver, or Intestinal Problems o Syphilis o Tuberculosis o Tumor o Thyroid Problems o Urinary Tract Infection o Other of Onset G. infectious diseases Disease Age Remarks Chicken Pox Hepatitis Measles Mumps Pertussis / Whooping Cough Pneumonia Polio Rubella Scarlet Fever Other

H.immunizations Booster 1 Booster 2 Booster 3 Immunization for Age Age Age Age Diphtheria Hepatitis B Measles Mumps Pertussis/Whooping Cough Polio Rubella Smallpox Tetanus Tuberculosis Typhoid Other I. allergies/drug sensitivities Allergy/Sensitivity Type (include medications, Reaction Last Occurred Treatment foods, environmental, or other)

J. Family member history Mother Father Sibling(s) Grandparent(s) Children Enter ages of relatives If deceased, indicate age and cause of death Check all items that apply for their present state of health or any illnesses they have had. Alcoholism Arthritis Asthma Cancer Diabetes Emphysema Glaucoma Heart Condition Hemodialysis Hepatitis High Blood Cholesterol High Blood Pressure Kidney Disease Mental Retardation Rheumatic Fever Seizures Smoking Stomach, Liver, or Intestinal Problems Stroke Thyroid Disorders Tuberculosis Tumor Other

K. lifestyle o Alcohol Drink(s) Per Week Number of Years o Smoking Pack(s) Per Day Number of Years o Exercise Type(s) of Exercise Days Per Week L. health log Noninfectious major illnesses. Include pregnancies and childbirth. Diagnosed Nature of Health Problem Age at Onset Condition Status Remarks (Such as, medications, special tests, x-rays, length of hospital stay, surgery, and so on)

medications (Prescription/Non-Prescription) Update Regularly Note: Include all prescription medications, (such as nitroglycerin) over-the-counter medications (taken on a regular basis), vitamin supplements, and herbal remedies.

N. doctor visits Diagnosis

O. hospitalizations ization Type (includes emergency room visits) Diagnosis Admission Discharge Complications ization Type (includes emergency room visits) Diagnosis Admission Discharge Complications ization Type (includes emergency room visits) Diagnosis Admission Discharge Complications

P. Surgeries Results Surgical Procedure Description Comments Results Surgical Procedure Description Comments Results Surgical Procedure Description Comments Results Surgical Procedure Description Comments

Q. lab or imaging (Examples: X-ray, mri, Mammogram) Test Type Test Type Requesting Administered by Requesting Administered by Result Result Test Type Test Type Requesting Administered by Requesting Administered by Result Result R. Medical Devices (Examples: pacemaker, insulin pumps, breathing devices) Device Type Device Type

S. physical/occupational Therapy Therapy Type Start Stop Frequency Therapist

T. Vision of Visit Physician of Visit Physician Vision RX Vision RX of Visit Physician of Visit Physician Vision RX Vision RX of Visit Physician of Visit Physician Vision RX Vision RX U. dental of Visit Dentist Problems Resolution

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