Special Communication Needs: Personal Health History ...

Name: ___________________________________________________________________ Date of Birth: _____________________

Address: ___________________________________________________________________________________________________

Local Phone Number: ________________________________ Alternative Phone Number: _____________________________

Please describe what problem or concern brought you to our office today:

K Primarily to establish care K Other (please briefly describe): __________________________________________________

Special Communication Needs:

Language Preference:

If "yes" to any of the questions below, how can we assist?

Visual Impairment

K Yes K No

Hearing Impairment

K Yes K No

Speech Impairment

K Yes K No

Cognitive Impairment

K Yes K No

Sensory Impairment

K Yes K No

Personal Health History

Previous Surgical Procedures

Please check past (P) or current (C) problems or conditions Please check if you have had any of the following:

K P K C Hypertension

K P K C Bowel/Digestive Problem Procedure

Year

K P K C High Cholesterol

K P K C Atrial Fibrillation

K Heart Surgery

K P K C Diabetes

K P K C Seizures

K Carotid Artery Surgery

K P K C Heart Attack or Angina K P K C Headaches

K Vascular Surgery / Stent

K P K C Irregular Heart Rhythm K P K C Stroke

K Abdominal Aneurysm Repair

K P K C Congestive Heart Failure K P K C Prostate Problem

K Hysterectomy

K P K C Emphysema or Chronic Bronchitis K P K C Breast Problem

K Gallbladder Removed

K P K C Pneumonia

K P K C Urinary Tract Infections K Appendix Removed

K P K C Gastroesophageal Reflux Disease K P K C Arthritis

K Tonsillectomy

K P K C Asthma

K P K C Thyroid Problem

K P K C Osteoporosis/Osteopenia K P K C Bleeding Disorder

K P K C Cancer, Type:

K P K C Addiction Issues

K Joint Replacement K Hip K Right K Knee K Right

K Left K Left

K P K C Stomach Ulcer K P K C Kidney Disease, Type:

K P K C Liver Disease, Type:

K P K C Depression K P K C Anxiety K P K C Mental Illness K P K C Other:

K Spine Surgery K Neck K Back K Breast Cancer Surgery K Prostate Cancer Surgery K Hernia K Other:______________________

Social History

Marital Status: K Single K Married K Divorced K Widowed K Life Partner

Live Here Year Round? K Yes K No If no, part time location:

Occupation:

Concerns: K Stress K Hazardous substances K Heavy Lifting

Tobacco Use: K Never K Quit (when) ____________ K Current Smoker ? Packs/day, how many years?

Alcohol Use: K No K Yes If yes, how many drinks/how often?

Caffeine Use: K No K Yes If yes ? K Coffee K Soda K Tea How many drinks/how often?

Illicit Drug Use (including Marijuana, Cocaine, Steroids): K Never K Past K Current Describe:

SARASOTA MEMORIAL HEALTH CARE SYSTEM NEWTOWN INTERNAL MEDICINE

ADULT HEALTH HISTORY QUESTIONNAIRE

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Current Health Concerns

Please check problems or conditions that you are CURRENTLY experiencing

K Chest Pain

K Rectal Bleeding

K Eye Pain

K Nervousness

K Shortness of Breath

K Black/Tarry Stools

K Loss of Vision

K Pain in Testicles

K Wheezing

K Weight Loss

K Double Vision

K Loss of Libido

K Cough

K Weight Gain

K Memory Loss

K Impotence

K Coughing Up Blood

K Loss of Appetite

K Ringing in Ears

K Breast Pain

K Sore Throat

K Difficulty Swallowing

K Pain in Ears

K Breast Discharge

K Nasal Congestion

K Diarrhea

K Nose Bleeds

K Other (please describe below)

K Irregular Heartbeat

K Constipation

K Hoarseness

K Fast Heartbeat

K Painful Urination

K Easy Bleeding

K High Blood Pressure

K Blood in Urine

K Easy Bruising

K Low Blood Pressure

K Urine Frequency

K Rash

K Lightheadedness

K Decrease in Urine Flow

K Changes in Mole

Females ? Please Complete

K Dizziness/Fainting K Abdominal Pain

K Urine Leakage K Headaches, frequent

K Sore that won't heal K Fatigue / Lethargy

Menstrual Flow: K Reg K Irreg. K Pain/Cramps

K Heartburn

K Hemorrhoids

K Insomnia

Days of flow_____ Length of cycle____

K Indigestion

K Loss of Strength

K Forgetfulness

1st day of last period:

K Ankle Swelling

K Balance Problems

K Depression

K Pain or bleeding after sex

K Nausea

Pain, weakness or numbness in

Number of pregnancies:

K Vomiting

K Arms

K Hips

K Back

Miscarriages:

K Vomiting Blood

K Legs

K Neck

K Shoulders

Birth Control Method:

K Change in Bowel Habits

K Hands

K Feet

K Abdomen

Menopause K Y K N Age:

Family History

Relationship Living Y/N Age

Major Medical Problems and/or Cause of Death

Father

Mother

Siblings

Children

Specifically, have any of your relatives had the following conditions:

Condition

Relative

Condition

Relative

K Mental Illness

K Chemical Dependency

K Diabetes

K Stroke

K Thyroid Disease

K Arthritis

K Pituitary Disease

K Dementia

K Crohn's / Colitis

K Hypertension

K Cancer, Type:

K Other:

Are there any religious or cultural factors that you would like us to take into account when planning your healthcare?

SARASOTA MEMORIAL HEALTH CARE SYSTEM NEWTOWN INTERNAL MEDICINE

ADULT HEALTH HISTORY QUESTIONNAIRE

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Health Maintenance:

Please check whether you have had the following preventive services and enter the year of the service

Immunizations

Last Occurrence

Tests

Last Occurrence

Tetanus Vaccine / Tdap

K Yes K No

Pap Smear / Pelvic

K Yes K No

Pneumonia Vaccine

K Yes K No

Mammogram

K Yes K No

Influenza Vaccine

K Yes K No

Bone Density

K Yes K No

Shingles Vaccine

K Yes K No

Colonoscopy

K Yes K No

Hepatitis K A K B

K Yes K No

Prostate Test

K Yes K No

Guardasil (HPV)

K Yes K No

Chest X-Ray

K Yes K No

Hospital Admissions (excluding pregnancies):

Date

Hospital

Reason for Admission

Allergies

Please list any allergies to medications or foods

Name

Symptom / Reaction

Medications:

Please list any medications that you take including over the counter medications, herbs, and supplements.

Name

Dose

Freq.

Name

Dose

Freq.

Pharmacy:_____________________________________________________ Phone:________________________ Store #: _________________ Location Description: ____________________________________________________________________________________________________

SARASOTA MEMORIAL HEALTH CARE SYSTEM NEWTOWN INTERNAL MEDICINE

ADULT HEALTH HISTORY QUESTIONNAIRE

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Specialty Providers

In order that we can best coordinate your care, please list any medical providers you see outside of this practice

Cardiologist

Nephrologist

Name: _________________________________________ Name: _________________________________________

Phone: _______________ Last Seen: ______________ Phone: _______________ Last Seen: ______________

Opthalmologist

Psychiatrist / Psychologist

Name: _________________________________________ Name: _________________________________________

Phone: _______________ Last Seen: ______________ Phone: _______________ Last Seen: ______________

Oncologist

Allergist

Name: _________________________________________ Name: _________________________________________

Phone: _______________ Last Seen: ______________ Phone: _______________ Last Seen: ______________

Urologist

Gynecologist

Name: _________________________________________ Name: _________________________________________

Phone: _______________ Last Seen: ______________ Phone: _______________ Last Seen: ______________

Gastroenterologist

Pulmonologist

Name: _________________________________________ Name: _________________________________________

Phone: _______________ Last Seen: ______________ Phone: _______________ Last Seen: ______________

Endocrinologist

Podiatrist

Name: _________________________________________ Name: _________________________________________

Phone: _______________ Last Seen: ______________ Phone: _______________ Last Seen: ______________

Other: _________________________________________ Other: _________________________________________ Name: _________________________________________ Name: _________________________________________ Phone: _______________ Last Seen: ______________ Phone: _______________ Last Seen: ______________

Other: _________________________________________ Other: _________________________________________ Name: _________________________________________ Name: _________________________________________ Phone: _______________ Last Seen: ______________ Phone: _______________ Last Seen: ______________

Patient / Guardian Signature: ______________________________________ Date: ___________ Time: ___________ AM / PM

SARASOTA MEMORIAL HEALTH CARE SYSTEM NEWTOWN INTERNAL MEDICINE

ADULT HEALTH HISTORY QUESTIONNAIRE

930284 Rev. 04/17 Page 4 of 4

PLACE PATIENT ID LABEL HERE

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