Patient Self-History Form - Nc
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1
2
31.
Last Name
First Name
MI
CONFIDENTIAL
2. Patient Number
-- H
NC Department of Health and Human Services
Public Health Nursing and Professional Development
3.
Date of Birth
Month
Day
Year
PATIENT SELF-HISTORY FORM
4. Race
1. White
2. Black/African American
3. American Indian/Alaska Native
4. Asian
5. Native Hawaiian/Other Pacific Islander
6. Other
If you are unsure about any question, leave it blank
Ethnicity: Hispanic/Latino Origin?
Yes
No
And ask the nurse for help.
5.
Gender
1. Male
2. Female
6.
County of Residence
A. IMPORTANT INFORMATION
(Please complete the following)
1. What is the reason for your visit today? _______________________________________________________________________________
2. Do you feel that you are in good health?
Yes
No
3. Emergency contact:_______________________________________________________________________________________________
4. May we contact you by mail?
Yes
No
by phone?
Yes
No Your phone # is
5. Are you seeing another doctor for any reason?
Yes
No
6. Do you have any allergies?
Yes
No If yes, what?
7. Highest grade completed in school___________________________________________________________________________________
B. List Serious Illness, Injuries, Hospitalizations, Operations:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
C. SELF & FAMILY MEDICAL HISTORY (Please put an X under YOU if you’ve had any of the following. Put an X under
FAMILY if either a parent, grandparent, brother, sister or child of yours has had any of the following)
YOU / FAMILY
YOU / FAMILY
1.
Abuse (physical, sexual, verbal, or emotional)
17.
Hernia
2.
Anemia, Sickle Cell Disease or Trait, Blood disorder
18.
High cholesterol, High blood pressure, Stroke
3.
Anorexia, Bulimia, other eating disorders
19.
HIV, AIDS
4.
Arthritis, joint problems, back problems
20.
Kidney or bladder problems, stones, dialysis
5.
Asthma, Bronchitis, other breathing problems
21.
Migraine or severe headaches
6.
Birth defects, genetic problems, Cystic Fibrosis
22.
Pain or numbness in arms or legs
7.
Bleeding problems, blood clots in legs or lung, etc.
23.
Physical disability
8.
Bowel problems
24.
Prostate problems
9.
Breast lumps, discharge, tenderness, other problems
25.
Rectal pain or bleeding, hemorrhoids or "piles"
10.
Cancers, tumors (including cervical or uterine)
26.
Rheumatic fever
11.
Depression, anxiety, mental illness
27.
Seizures ("fits")
12.
Diabetes (sugar problems)
28.
Stomach pain, cramps, ulcers
13.
Eye problems, blurred vision or spots
29.
Thoughts of harming self or others
14.
Fainting, dizzy spells
30.
Thyroid problems
15.
Heart disease, heart problems, chest pain
31.
Transfusions of blood or blood products
16.
Hepatitis, liver problems, gallbladder problems
32.
Tuberculosis
Provider/Nurse Comments ONLY:
D. Infectious Diseases (Please put an (X) by all that you have had)
1.
Measles
6.
Chicken Pox
11.
Any Sexually Transmitted Diseases
2.
Mumps
7.
Meningitis
12.
Other: _______________________________________________
3.
Rubella
8.
Hepatitis A or B
____________________________________________________
4.
Tetanus
9.
Scarlet Fever
____________________________________________________
5.
Whooping Cough
10.
Rheumatic Fever
____________________________________________________
E. Vaccine History
Date
Vaccine
Date
Other Vaccines
Date
Tetanus shot (Td)
____________
Chicken Pox
____________
__________________
_____________
Measles shot (MMR)
____________
Hepatitis B series
____________
__________________
_____________
Influenza (Flu)
____________
Pneumonia
____________
__________________
_____________
DHHS 4060-E (03/05)
PHNPD (Review 07/07)
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