Va Gateway Urgent Care Center Medical History Page 2
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2VA Gateway Urgent Care Center Medical History
Name __________________________
Please List and Supply the Dates of:
Operations _________________________ __________________________________ ___________________________________
_________________________ __________________________________ ___________________________________
Hospitalizations other than surgery
__________________________________ ___________________________________
_________________________ __________________________________ ___________________________________
Immunization history-have you had:
Pneumovax immunization?
No
Yes
When? _______________
Hepatitis B?
No
Yes
When? _______ Flu immunization?
No
Yes
When? _______________
Other?
No
Yes
When? _______ Tetanus immunization?
No
Yes
When? _______________
When was your last:
Pap Smear? ________________Breast Exam? _________________Mammogram?______________ Thyroid Check?_____________
Stool check for blood?_______________ Testicular Exam?_________Sigmoidoscopy/Colonoscopy?___________________________
Cholesterol check?________________Prostate exam?_________________PSA?__________________Eye Exam?_______________
Dental Check-up?______________________Skin Cancer Screen?___________________Urine Analysis?______________________
Family History
Has any member of your family (including parents, grandparents, and siblings) ever had the following?
Illness
Which family members?
Age when diagnosed
Cancer (describe type)
________________________________________________ _____________________
Hypertension (high blood pressure)
________________________________________________ _____________________
Heart Disease or unexplained sudden death ________________________________________________ _____________________
Diabetes
________________________________________________ _____________________
Strokes
________________________________________________ _____________________
Mental disease (anxiety, depression, etc.)
________________________________________________ _____________________
Drug or alcohol addition
________________________________________________ _____________________
Glaucoma
________________________________________________ _____________________
Bleeding diseases or blood clots
___________________________________________
_____________________
Other
________________________________________________ _____________________
Current Medications (Prescription, Over-the-Counter, Vitamins, Herbs, etc.)
Drug Name
Dose
Drug Name
Dose
Drug Name
Dose
__________________________________ __________________________________ ___________________________________
__________________________________ __________________________________ ___________________________________
__________________________________ __________________________________ ___________________________________
__________________________________ __________________________________ ___________________________________
Prevention
Do you wear seat belts?
Yes
No
If no, why not? ____________________________________
Do you wear a bike helmet?
Yes
No
N/A
Do you exercise regularly?
Yes
No
If yes, type, duration and number of times per week?
_________________________________________________
Do you smoke?
Yes
No
If yes, how many packs per day? ______________________
Do you drink alcoholic beverages?
Yes
No
If yes, how much per week? __________________________
Do you drink coffee or tea?
Yes
No
If yes, how many cups per day? _______________________
If there is a gun in your home, do you keep it
Yes
No
N/A
unloaded and out of children’s reach?
Do you use drugs? (marijuana, cocaine, crack, etc.) Yes
No
If yes, explain: _____________________________________
Have you ever engaged in any activity which has
Yes
No
If yes, explain: _____________________________________
put you at risk of getting AIDS?
Do you wish to be tested for AIDS?
Yes
No
Have you ever worked with chemicals, paints,
Yes
No
If yes, explain: _____________________________________
asbestos, or other hazardous materials?
Are you in a relationship in which you have been
Yes
No
physically hurt (e.g., slapped, kicked, punched,
bruised) by your partner?
Do you have a “living will”?
Yes
No
Do you have a donor card?
Yes
No
Method of birth control? ______________________________________________________________________________________
This information is for use by your physician as part of your confidential medical record.
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