Download PATIENT HEALTH HISTORY

PATIENT HEALTH HISTORY
Name: ________________________________ DOB:______________ Age: ______ Date: _______________
Referred by: _______________________________ Emergency Contact: _____________________________
Marital Status (please circle):
Married
Single
Divorced
Widowed
Occupation: _________________________ Place of Employment: _________________________________
Problem today, if any ______________________________________________________________________
Medication allergies
1.____________________________________ 5.____________________________________
2.____________________________________ 6.____________________________________
3.____________________________________ 7.____________________________________
4.____________________________________ 8.____________________________________
Current medications
1. ____________________________________ 5.____________________________________
2. ____________________________________ 6.____________________________________
3. ____________________________________ 7.____________________________________
4. ____________________________________ 8.____________________________________
Other physicians you see and their specialty:
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
Date of last:
Mammogram: _________________________________ Bone density test: _____________________
Colonoscopy:__________________________________
History of Abnormal Pap (please circle) Y
N
History of Abnormal Mammogram (please circle) Y
N
First day of last menstrual cycle:________________________________
Number of pregnancies:___________________
How many children do you have:___________________
Smoking History (please circle):
Current smoker
Never smoked
(additional questions on reverse)
Past smoker
Past surgeries:
1.___________________________________________________________
2.___________________________________________________________
3.___________________________________________________________
4.___________________________________________________________
5.___________________________________________________________
MRSA QUESTIONS
1.
Have you had any open sores, wounds, spider bites or boils in the past year?
___Yes ___No
2.
Have you ever been treated for MRSA or a staph infection?
___Yes ___No
3.
Have you received antibiotics in the last year for a skin or wound infection?
___Yes ___No
FAMILY HISTORY
Please circle Y to those that apply to YOU and/or YOUR FAMILY, on both your mother’s and father’s side. Next to
each statement, please list the relationship to you of the individual diagnosed and their age at diagnosis.
RELATIONSHIP
AGE AT DIAGNOSIS
BREAST AND OVARIAN CANCER
Y
N
Personal Breast Cancer before age 50
____________
_______________
Y
N
Ovarian Cancer
____________
_______________
Y
N
Male breast cancer
____________
_______________
Y
N
2 or more breast or ovarian cancers
____________
_______________
Y
N
Ashkenazi Jewish ancestry & personal
Or family history of breast or ovarian cancer
____________
_______________
COLON AND UTERINE CANCER
Y
N
Personal Uterine cancer before age 50
____________
_______________
Y
N
Personal Colorectal cancer before age 50
____________
_______________
Y
N
2 or more uterine or colorectal cancers
____________
_______________
Signed _____________________________________________
Date _________________