Form Rfmc 212 - Patient Health History Form Page 2
ADVERTISEMENT
1
2HABITS:
HABITS:
Check here if your health history hasn’t changed since your last visit.
Check here if your health history hasn’t changed since your last visit.
(Circle answers and fi ll in as appropriate)
(Circle answers and fi ll in as appropriate)
HABITS:
Check here if your health history hasn’t changed since your last visit.
Tobacco?
Tobacco?
YES
YES
QUIT
QUIT
NEVER
NEVER
(Circle answers and fi ll in as appropriate)
Present Concerns: __________________________________
Present Concerns: __________________________________
Tobacco?
YES
QUIT
NEVER
SMOKE
SMOKE
E Cigarettes
CHEW
CHEW
YES
SNUFF
SNUFF
NO
Present Concerns: __________________________________
_________________________________________________
_________________________________________________
SMOKE
CHEW
SNUFF
Amount Per Day _____________________________
Amount Per Day _____________________________
_________________________________________________
_________________________________________________
_________________________________________________
Amount Per Day _____________________________
Years Spent ________________________________
Years Spent ________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Alcohol?
Alcohol?
Years Spent ________________________________
YES
YES
QUIT
QUIT
NEVER
NEVER
_________________________________________________
Alcohol?
YES
QUIT
NEVER
Times per week _____________________________
Times per week _____________________________
_________________________________________________
_________________________________________________
Times per week _____________________________
_________________________________________________
Amount per time ____________________________
Amount per time ____________________________
Current Medical Conditions: __________________________
Current Medical Conditions: __________________________
Amount per time ____________________________
Ever felt like you ought to cut down?
Ever felt like you ought to cut down?
YES
YES
NO
NO
Current Medical Conditions: __________________________
_________________________________________________
_________________________________________________
Ever felt like you ought to cut down?
YES
NO
Have people annoyed you by criticizing your drinking?
Have people annoyed you by criticizing your drinking?
YES
YES
NO
NO
_________________________________________________
_________________________________________________
_________________________________________________
Have people annoyed you by criticizing your drinking?
YES
NO
Have you felt guilty about your drinking?
Have you felt guilty about your drinking?
YES
YES
NO
NO
_________________________________________________
_________________________________________________
_________________________________________________
Have you felt guilty about your drinking?
YES
NO
Have you ever had an ‘eye-opener’ morning drink?
Have you ever had an ‘eye-opener’ morning drink?
YES
YES
NO
NO
_________________________________________________
_________________________________________________
_________________________________________________
Have you ever had an ‘eye-opener’ morning drink?
YES
NO
Other Drugs?
Other Drugs?
YES
YES
QUIT
QUIT
NEVER
NEVER
_________________________________________________
Previous Hospitalizations: ____________________________
Previous Hospitalizations: ____________________________
Other Drugs?
YES
QUIT
NEVER
Which drugs? ________________________
Which drugs? ________________________
(i.e. Marijuana)
(i.e. Marijuana)
Previous Hospitalizations: ____________________________
_________________________________________________
_________________________________________________
Which drugs? ________________________
(i.e. Marijuana)
_________________________________________________
_________________________________________________
_________________________________________________
Do you exercise regularly?
Do you exercise regularly?
YES
YES
NO
NO
_________________________________________________
Do you exercise regularly?
YES
NO
_________________________________________________
_________________________________________________
Which exercises? __________________________________
Which exercises? __________________________________
_________________________________________________
Which exercises? __________________________________
________________________________________________
________________________________________________
_________________________________________________
_________________________________________________
________________________________________________
How many times per week? __________________________
How many times per week? __________________________
_________________________________________________
Previous Surgeries: _________________________________
Previous Surgeries: _________________________________
How many times per week? __________________________
Previous Surgeries: _________________________________
_________________________________________________
_________________________________________________
Do you follow a special diet?
Do you follow a special diet?
YES
YES
NO
NO
_________________________________________________
_________________________________________________
_________________________________________________
Do you follow a special diet?
YES
NO
Know your cholesterol levels? YES
Know your cholesterol levels? YES
NO
NO
_________________________________________________
Know your cholesterol levels? YES
NO
Total _____ HDL _____ LDL _____ Triglyceride ___________
Total _____ HDL _____ LDL _____ Triglyceride ___________
_________________________________________________
_________________________________________________
Total _____ HDL _____ LDL _____ Triglyceride ___________
_________________________________________________
_________________________________________________
_________________________________________________
Wear seat belts?
Wear seat belts?
YES
YES
NO
NO
SOME
SOME
_________________________________________________
Allergies: _________________________________________
Allergies: _________________________________________
Wear seat belts?
YES
NO
SOME
Wear a bike helmet?
Wear a bike helmet?
YES
YES
NO
NO
SOME
SOME
Allergies: _________________________________________
_________________________________________________
_________________________________________________
Wear a bike helmet?
YES
NO
SOME
Have a smoke detector?
Have a smoke detector?
YES
YES
NO
NO
_________________________________________________
_________________________________________________
_________________________________________________
Carbon monoxide detector?
Carbon monoxide detector?
Have a smoke detector?
YES
YES
YES
NO
NO
NO
_________________________________________________
Carbon monoxide detector?
YES
NO
Adult / infant CPR training?
Adult / infant CPR training?
YES
YES
NO
NO
_________________________________________________
_________________________________________________
Adult / infant CPR training?
YES
NO
If you own a gun, is it secured?
If you own a gun, is it secured?
YES
YES
NO
NO
N / A
N / A
_________________________________________________
_________________________________________________
_________________________________________________
If you own a gun, is it secured?
YES
NO
N / A
(Women) Self Breast Exam?
(Women) Self Breast Exam?
YES
YES
NO
NO
_________________________________________________
Current Medications: _______________________________
Current Medications: _______________________________
(Women) Screening Mammogram?
(Women) Screening Mammogram?
(Women) Self Breast Exam?
YES
YES
YES
NO
NO
NO
Current Medications: _______________________________
_________________________________________________
_________________________________________________
(Women) Screening Mammogram?
YES
NO
(Men) Self Testicular Exam?
(Men) Self Testicular Exam?
YES
YES
NO
NO
_________________________________________________
_________________________________________________
_________________________________________________
FAMILY:
FAMILY:
(Men) Self Testicular Exam?
YES
NO
(Circle answers and fi ll in as appropriate)
(Circle answers and fi ll in as appropriate)
_________________________________________________
FAMILY:
LIVING
LIVING
AGE
AGE
HEALTH CONDITIONS
HEALTH CONDITIONS
(Circle answers and fi ll in as appropriate)
_________________________________________________
_________________________________________________
MOTHER ___________
MOTHER ___________
Y N _____ _______________
Y N _____ _______________
LIVING
AGE
HEALTH CONDITIONS
_________________________________________________
_________________________________________________
_________________________________________________
MOTHER ___________
Y N _____ _______________
FATHER ____________
FATHER ____________
Y N _____ _______________
Y N _____ _______________
_________________________________________________
_________________________________________________
_________________________________________________
FATHER ____________
Y N _____ _______________
SIBLINGS
SIBLINGS
_________________________________________________
_________________________________________________
_________________________________________________
1. M ______ F ______
1. M ______ F ______
SIBLINGS
Y N _____ _______________
Y N _____ _______________
_________________________________________________
1. M ______ F ______
Y N _____ _______________
2. M ______ F ______
2. M ______ F ______
Y N _____ _______________
Y N _____ _______________
OBSTETRIC HISTORY: (Fill in as appropriate)
OBSTETRIC HISTORY: (Fill in as appropriate)
2. M ______ F ______
Y N _____ _______________
OBSTETRIC HISTORY: (Fill in as appropriate)
3. M ______ F ______
3. M ______ F ______
Y N _____ _______________
Y N _____ _______________
Pregnancy Date(s)
Pregnancy Date(s)
Outcome (i.e. Vaginal Birth)
Outcome (i.e. Vaginal Birth)
3. M ______ F ______
Y N _____ _______________
4. M ______ F ______
4. M ______ F ______
Y N _____ _______________
Y N _____ _______________
Pregnancy Date(s)
Outcome (i.e. Vaginal Birth)
______________________
______________________
______________________
______________________
5. M ______ F ______
5. M ______ F ______
4. M ______ F ______
Y N _____ _______________
Y N _____ _______________
Y N _____ _______________
______________________
______________________
______________________
______________________
______________________
______________________
5. M ______ F ______
Y N _____ _______________
6. M ______ F ______
6. M ______ F ______
Y N _____ _______________
Y N _____ _______________
______________________
______________________
______________________
______________________
______________________
______________________
6. M ______ F ______
Y N _____ _______________
CHILDREN (List names of children)
CHILDREN (List names of children)
______________________
______________________
CHILDREN (List names of children)
1 _________________
1 _________________
Y N _____ _______________
Y N _____ _______________
______________________
______________________
______________________
______________________
1 _________________
Y N _____ _______________
2 _________________
2 _________________
Y N _____ _______________
Y N _____ _______________
______________________
______________________
SEXUAL HISTORY: (Circle answers and fi ll in as appropriate)
SEXUAL HISTORY: (Circle answers and fi ll in as appropriate)
2 _________________
Y N _____ _______________
3 _________________
3 _________________
Y N _____ _______________
Y N _____ _______________
SEXUAL HISTORY: (Circle answers and fi ll in as appropriate)
Are you sexually active? YES NO NOT CURRENTLY
Are you sexually active? YES NO NOT CURRENTLY
3 _________________
Y N _____ _______________
4 _________________
4 _________________
Y N _____ _______________
Y N _____ _______________
Are you sexually active? YES NO NOT CURRENTLY
Sexual Partners: MALE(S) FEMALE(S) BOTH
Sexual Partners: MALE(S) FEMALE(S) BOTH
5 _________________
5 _________________
4 _________________
Y N _____ _______________
Y N _____ _______________
Y N _____ _______________
Sexual Partners: MALE(S) FEMALE(S) BOTH
5 _________________
Y N _____ _______________
Method of Contraception: _____________________________
Method of Contraception: _____________________________
Method of Contraception: _____________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical