Form Yp-0878 Medical History Form printable pdf download

Date: ______________________________________________ Date of birth: ___________________________________________

Name: ______________________________________________ Alias/ Nicknames: _______________________________________

Main Reason for visit: ______________________________________________________________________________________

MEDICAL HISTORY: (note year diagnosed with details)

SOCIAL HISTORY:

c Asthma

_______________________________

Single Married

Widowed

Divorced

Separated

c Bladder /Kidney disorders

_______________________________

Children:

None

Occupation: _____________________________________

c Blood Disorders

_______________________________

c Breast / GYN disorders

_______________________________

Years of education/highest degree: ________________

c Cancer (____________________) _______________________________

Tobacco Use:

c Chronic eye/ear/nose disorders _______________________________

Cigarettes: c Never

c Quit year ________________

c Depression/anxiety

_______________________________

c Current smoker: packs/day ____ # of years _______

c Diabetes

_______________________________

Other Tobacco: c pipe c cigar

c snuff

c chew

c Gastrointestinal disorders

_______________________________

Are you interested in quitting? c Yes

c No

c Heart disorders

_______________________________

Drink caffeine: c Yes c No Cups per day _______

c High blood pressure

_______________________________

c High Cholesterol

_______________________________

Alcohol Use:

c Yes c No # drinks/week _______

c Lung/COPD/Emphysema

_______________________________

Is your alcohol a concern for you or others?

c Neurologic/ Stroke/ Seizure

_______________________________

c Yes c No

c Prostate Problems

_______________________________

Drug Use:

c Skin disorders

_______________________________

Have you used any recreational drugs? c Yes c No

c Thyroid disorders

_______________________________

Have you ever used needles to inject drugs?

c Others

_______________________________

c Yes c No

SURGERIES (major) (Note Year)

Sexual Activity:

c Abdominal

________________

c Orthopedic ___________

Sexually active:

c Yes

c No c Not currently

c Appendix

________________

c Prostate ______________

Current sex partner(s): c Male c Female

c Breast

________________

c Uterus / Ovary _________

Birth Control method: ______________ c none needed

c Gall bladder ________________

c Other ________________

Have you ever had a sexually transmitted disease(s)

c Heart

________________

(STD’s)?

c Yes c No

Other Concerns:

Are you interested in being screened for sexually

Weight: Is your weight a concern?

c Yes c No

transmitted diseases? c Yes c No

Diet: How do you rate your diet?

c Good c Fair c Poor

PAST TESTS:

Year last done

Exercise: Do you exercise regularly?

c Yes c No

Bone Density Scan

N _________________

What kind of exercise?___________________________________

Colonoscopy

N _________________

How long (minutes) ___________ How often? ______________

Mammogram

N _________________

Safety: Is violence at home a concern for you? c Yes c No

PAP test (female)

N _________________

Have you ever been abused?

c Yes c No

PSA (prostate)

N _________________

Do you fall frequently?

c Yes c No

Treadmill (heart)

N _________________

Have you completed a living will or

durable power of attorney for health care?

c Yes c No

MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs:

TIMES

MEDICATION

DOSE

MEDICATION

DOSE

PER DAY

PATIENT ID

Name ___________________________________________

HERITAGE

HEALTHCARE

MRN ____________________________________________

PATIENT HISTORY FORM

Date of Birth _____________________________________

Side 1

Date of Service ___________________________________

YP-0878 (9/29/11)

PMM # 293912

Form Yp-0878 Medical History Form

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