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PATIENT HISTORY FORM
PERSONAL INFORMATION:
Name:
_ Date:
_
Date of Birth:
_
Age:,
_ Sex: __M _ _F
Marital Status: __Single Occupation:
Married
Divorced _
Widowed
Remarried
Spouse Nlll'J..le:
_ Spouse's Occupation:
_
List people in your household, relationship and year of birth:
DRUG ALLERGIES/ADVERSE DRUG REACTIONS/OTHER ALLERGIES:
CURRENT MEDICAL HISTORY:
How do you rate your present health status?
Excellent
What do you regard as your main medical problem(s)?
Good
Fair __Poor
Please list all prescriptions or over-the-counter medications with dose and frequency taken including vitamins and herbs:
Example: Motrin 400mg 3times. a day:
'
Please list any other source of health care (physician clinic, urgent care, laboratory, radiology, therapist, chiropractor, etc...) Provider or Site
Patients Initials:
_
Provider Initials:
Patient History FOTITl Rev. 01/28104
PLEASE COMPLETE ALL FOUR PAGES OF TIllS FORM
Item# 60701 Form# WS0161
_ Page 1 of4
WEL!STAR.
~ Physicians Oroup
PERSONAL HABITS Do you wear seatbelts?
YES NO
0
0
PREVIOUS 0
Patient Name: Birth Date:
Do you exercise regularly?
0
0
0
times/wk Type:
Do you smoke? Do you chew tobacco?
0
0
0
0
0
0
packs/day Num~r of years: packs/day Number of years:
Do you drink alcohol?
0
0
0
drinks/day Number of years:
Do you drink caffeine?
0
0
0
drinks/day Number ofyears:
Do you experience difficulty with
drugs, alcohol or other substances? 0
0
o If Yes, specify:
_
Have you ever had: Blood Transfusion
YES NO
0
0
Any additional information:
I.V. Drug Use
0
0
Unsafe Sex
0
0
Sexually Transmitted Disease
0
0
PAST MEDICAL HISTORY: I. Indicate any operations you have had and the year performed:
2. Indicate all hospitalizations you have had for non-surgical illnesses and give the year hospitalized if possible:
3. Indicate any major adult or childhood illnesses with the year of the illness:
4. If you have had any of the following, please check and indicate date if possible:
Date
Date
Date / Results
Physical Exams
_
Dental Exam - - - - - - EKG
/
_
Tetanus shot
Eye Exam
Stress Test
/
_
Flu shot PSA Rubella Shot
Rectal Exam
_
Pneumonia shot - - - - -
Hepatitis Shot
_
Blood Pressure ---~/-----
Cholesterol
/- - - -
Sigmoidoscopy ~
/_~
_
Patients Initials:
Patient History Form Rev.Ol/28/04
_
Provider Initials:
_
PLEASE COMPLETE ALL FOUR PAGES OF THIS FORM
Page 2 of4
Patient Name:
Birth Date:
~
FAMILY mSTORY: Please give approximate date of onset of each disease, if known:
Year ofBirth Year ofDeath Cause of Death Heart Disease High Bloo~ Pressure High Cholesterol Anemia Stroke Diabetes Cancer (type) Kidney Disease Asthma Tuberculosis Migraines Alcohol Abuse Drug Abuse . Mental Problems Other: . Other:
Father
Mother
BroDSis 0 BroD Sis 0
BroOSis 0
Bro OSis D
FOR WOMEN ONLY:
Date oflast menstrual period:
_
Number of pregnancies:_ _~
_
Difficulty with periods?
_ Y_N
Number of live births:
_
Describe:.
_
Ifmenopausal, date of onset:.
_
Changes in menstrual pattern? _ _V _ _N
Describe:
_
When was your last Pap Smear?
_
Date of last mammogram:.
_
Do you practice breast self exam? _ _ _V
N
What is your method of birth control?
_
FOR MEN ONLY:
Do you practice testicular self-exams? _ _V _ _N Need Instruction:.
_
Have you ever had a Prostate Screening Test? ~_Y __N Date:
_
What method ofbirth control do you use?
Patients Initials:
_
Provider Initials:.
_
Patient History Form Rev. 01/28/04
PLEASE COMPLETE ALL FOUR PAGES OF THIS FORM
Page 3 of4
WEt~TAR?.
~Pttv$ician~ Group
PLEASE CHECK ANY RECENT OR RECURRING PROBLEMS YOU HAVE EXPERIENCED:
___Abdominal Pain _ _Back Pain
__Rapid Heart Rate Fever Skin Rash
_ _Depression ~_Lack ofEnergy _ _Hay Fever _ _Problem Hearing
~_Fainting
_ _Bleeding _ _Vaginal Discharge _ _Weight Gain
Chills Violence at home
_ _Difficulty Swallowing _ _Joint Pain _ _Wheezing _ _Swollen Glands _ _Swelling of Extremities _ _Anxiety _ _. Constipation _ _Nasal Congestion _ _Vision Problems? _ _Abnormal Vaginal Bleeding
Pelvic Pain _ _Poor Appetite __Weight Loss _ _Unsafe work conditions _ _Hazardous work or hobbies
_ _Heartburn
_ _Chest Pain _ _Cough
__Shortness ofBreath _ _Di~cultySleeping _ _Reaction to Anesthesia
~_Nausea
_ _Headaches _ _Dizziness
__ Rectal Bleeding _ _Hot Flashes _ _Burning wfUrination _ _Diarrhea
_ _Sexual Difficulties
COMMUNICATION NEEDS:
Language if other than English:
Vision:
Normal _ _Glasses _ _Contacts _ _Blind
Hearing:
Normal _ _ Hard of Hearing _ _ Hearing Aid
Deaf
Interpreter Needed:
Y
N
Did someone else fill out this form? _ _V
N Who?_ _~
PATIENT RIGHTS:
Is there anything we need to know about your religion or culture in order to care for you?
/fYES, explain:
_
AnVANCE DIRECTIVES:
Do you have an Advance Directive: _ _V _ _N
IfYES, do you have: Living Will
Durable Power of Attorney for Healthcare Directive for Final Healthcare
_ _Y _ _N
Y_N
_ _Y _ _N
Who would you want to make decisions for you in the event you are unable to make them for yourself?
_
If you have an Advance Directive, please bring us a copy for your chart.
Patient Signature,?
_
Date
Provider Signature:.
Patient Histoly form Rev.OI1l8/Q4
_
Date:
PLEASE COMPLETE ALL FOUR PAGES OF THIS FORM
_ Page 4 of4
................
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