Interval History Form printable pdf download

INTERVAL HISTORY

Name:_______________________________DOB:___________________________ Today’s Date: ___________________________

ADVANCED DIRECTIVE: Do you have an Advanced Directive/ Durable Power of Attorney for health care? □ Yes □ No

MEDICAL HISTORY: Please list all other doctors you see and the reason(s) you see them: __________________________________

Any new diagnoses, hospitalizations, medical problems or surgeries since last physical: _______________________________________

_____________________________________________________________________________________________________________

CURRENT MEDICATIONS: List all current medications, supplements and vitamins you are currently taking. (use back if needed)

Medication

Dose

How often you take it

What you take it for

When it was started

Refill needed?

WOMEN’S HEALTH:

Date of last pap test:

Ever had an abnormal pap: □ No □Yes, dates:

Treatment:

Form of birth control:

Menstrual cycles are: □ Regular □ Irregular , explain:

□ Menopause at age:

Date of last mammogram:

Date of last bone density test:

FAMILY HISTORY: Please check the boxes that apply to your family

Family member

Alive

Year

Breast

Diabetes

Heart

Colon

Asthma

Ovarian

Other

cancer

disease

cancer

birth

Father:

□

Mother:

□

Brother:

□

Sister:

□

Children

□

Paternal Grandfather:

□

Paternal Grandmother:

□

Maternal Grandfather:

□

Maternal Grandmother:

□

Other:

□

SOCIAL HISTORY:

Marital Status

□ Single

□ Married

□ Separated

□ Divorced

□ Widowed

Occupation:

Exercise (type, frequency)

Tobacco

□ Yes □ Smoked in past, quit in _______. # of packs per day _____. # of years _____

Ready to quit? ____

Alcohol

_____ glasses/day OR_____glasses/week. Problems due to alcohol? □ No □ Yes, explain: ____________

Recreational Drugs

□ No □ Yes, please explain:

Ready to quit?

Domestic Violence

Are you involved in domestic violence □ No □ Yes, please explain

regularly or out of the ordinary.

REVIEW OF SYSTEMS: Please check if you have any of the symptoms below

Constitution

□ blurring of vision

Gastroenterology

□ dryness

□ redness

□ headache

□ sudden blindness

□ abdominal pain

□ rash

□ cramps

□ dizziness

□ double vision

□ vomiting

□ bruising

□ muscle/tendon injury

□ fainting

Endocrinology

□ diarrhea

□ changing/new mole

Psychiatry

□ fatigue

□ excessive thirst

□ bloody or black stool

Neurology

□ nerves

□ weight change

□ cold intolerance

□ constipation

□ paralysis

□ depression

□ fever

□ heat intolerance

□ jaundice

□ numbness

□ insomnia

Ears/nose/throat

Cardiology

Urology

□ weakness

□ anxiety

□ hearing loss

□ chest pain

□ erectile dysfunction

□ convulsions

Women’s Health

□ ringing in the ears

□ palpitations

□ burning

Hematology/Lymph

□ spotting

□ loss of balance

Respiratory

□ increased frequency

□ bleeding

□ painful intercourse

□ nose bleeds

□ cough

□ bloody or dark urine

□ swollen glands

□ severe cramps

□ chronic drainage

□ wheeze

□ incontinence

Musculoskeletal

□ breast lumps or pain

□ sore throat

□ shortness of breath

□ decreased flow

□ frequent back pain

□ excessive bleeding

□ difficulty swallowing

□ chronic phlegm

□ dribbling

□ sciatica

□ breast discharge

Eyes

□ coughing up blood

Dermatology

□ extremity swelling

□ vaginal discharge

_____________________________________________________

OTHER CONCERNS YOU WOULD LIKE TO DISCUSS:

___________________________________________________________________________________________________

Interval History Form

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