Patient Health History Form - cdndata.co · Health Maintenance. Date of your last colonoscopy? Date of your last pap smear? Date of your last eye exam? Date of your last mammogram?

The Doctor Is In, PA Patient Health History Form

Health History

Check (√) all items either No or Yes No Yes, Now Yes, Past Check (√) all items either No or Yes No Yes, Now Yes, Past

Abnormal EKG Headaches (Frequent)

Alcoholism Heart Attack or Heart Disease

Anemia or Low Blood Hepatitis Type A, B or C (circle)

Anxiety Hernia

Arthritis or Sore Joints High Blood Pressure

Asthma or Hay Fever High Cholesterol

Bleeding or Bruising HIV/AIDS

Broken Bones Kidney or Bladder Problems

Bronchitis or Emphysema Leg or Foot Pain

Cancer Phlebitis or Blood Clots

Cataracts Shortness of Breath

Chemical Dependency Skin Disease or Psoriasis or Eczema

Chest Pain Stomach Problems or Ulcers

Circulation Problems Stool or Bowel Problems

Deafness or Dizziness or Ringing Ears Stroke

Depression or Sadness Thyroid Problem

Diabetes Tuberculosis or Positive TB Test

Fatigue or Tiredness or Weakness Weight Loss or Gain (circle one)

Glaucoma Other:

Gout Other:

TDII Patient Health History12/2013

1

Medications Please list all medications you are now taking, including those you buy without a doctor’s prescription (over-the-counter, supplements, herbals, etc.)

1. 7. 2. 8. 3. 9. 4. 10. 5. 11. 6. 12. Other: Other:

Health Maintenance Date of your last colonoscopy? Date of your last pap smear?

Date of your last eye exam? Date of your last mammogram?

Date of your last wellness exam? Date of your last bone density test?

What type of birth control is used between you and your partner? Do you consider yourself Underweight Normal weight Overweight Obese

What kind of exercise do you do? How often do you exercise?

Do you have a Living Will? No Yes Where? Do you wear seat belts? No Yes

If No, would you like information on Living Wills? No Yes Do you text while driving? No Yes

Do you feel safe at home? No Yes Do you use sunscreen? No Yes

TDII Patient Health History12/2013

2

Habits Allergies Do You: If Yes, how much? List anything that you are allergic to (medications, foods, bee sting, etc.)

and how each affects you. Use Tobacco No Yes 1. Reaction: Drink Caffeine No Yes Cups/Day 2. Reaction: Drink Alcohol No Yes Drinks/Day 3. Reaction: Use Street Drugs No Yes 4. Reaction: Exercise No Yes 5. Reaction:

Hospitalizations (not including normal pregnancies) Serious Illness (not requiring hospitalization) 1. Year 1. Year 2. Year 2. Year 3. Year 3. Year 4. Year 4. Year

Check (√) either No or Yes. If Yes, please check (√) the family member who has (or in the past had) any of the medical problems listed.

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Check (√) either No or Yes. If Yes, please check (√) the family member who has (or in the past had) any of the medical problems listed.

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Alcoholism 0 No 0 Yes Heart Disease 0 No 0 Yes Allergies 0 No 0 Yes High Blood Pressure 0 No 0 Yes Arthritis 0 No 0 Yes Kidney Disease 0 No 0 Yes Asthma or Lung Problems 0 No 0 Yes Liver Disease 0 No 0 Yes Cancer 0 No 0 Yes Mental Illness 0 No 0 Yes Colon or Bowel Problems 0 No 0 Yes Migraines 0 No 0 Yes Diabetes 0 No 0 Yes Stroke 0 No 0 Yes Emphysema 0 No 0 Yes Other Significant Family History