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Download Patient History - ADULT - Wilson Health Medical Group
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Wilson Health Medical Group A Service of Wilson Health New Patient Personal Medical History Name ____________________________________________________ Date: ______________________ Last First Date of Birth: _____ - _____ - _____ MI Sex: ____M ____F Last four of SSN # ____________ Medical History Please indicate if you have any of the following by placing an ‘X’ by the condition: _____ Alcoholism _____ Emphysema _____ Kidney/Bladder Disease _____ Angina _____ Epilepsy/Seizures _____ Leukemia _____ Anemia _____ Fibromyalgia _____ Liver Disease _____ Arthritis _____ Gastroesophageal Reflux Disease _____ Lung Disease _____ Asthma _____ Glaucoma _____ Multiple Sclerosis _____ Blood clotting disorders _____ Headache/Migraines _____ Osteoporosis _____ Bowel Problems _____ MRSA _____ Pacemaker _____ Cancer _____ Heart Attack/MI _____ Psychiatric Disorders _____ Cholesterol Disease _____ Heart Disease _____ Sexually Transmitted Diseases _____ COPD _____ Heart Murmur _____ Skin Disorders _____ Congestive Heart Failure(CHF) _____ Heart Rhythm Abnormalities _____ Stroke _____ Coronary Heart Disease _____ Hepatitis _____ Thoughts of Suicide _____ Depression/Anxiety _____ High Blood Pressure _____ Thyroid Disease _____ Diabetes _____ HIV/AIDS _____ Tuberculosis If any of the above were checked please explain or add items not listed: _________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________________________________________________ _________________________________________________________________________________________ Allergies Please list all allergies, medications and seasonal; indicate reaction (use extra space at end if needed): Allergy Reaction ______________________________________ _________________________________________ ______________________________________ _________________________________________ ______________________________________ _________________________________________ ______________________________________ _________________________________________ ______________________________________ _________________________________________ ______________________________________ _________________________________________ ______________________________________ _________________________________________ Adult History 1 Medical History Please indicate if you have any of the following by placing an ‘X’ by the condition: General: ___ Weight loss ___ Fever ___ Chills Skin: ___ Rash ___ Hair loss HEENT: ___ Headaches ___ Visual impairment Neck: ___ Pain ___ Swelling Respiratory: ___ Shortness of breath ___ Cough Breast: ___ Mass ___ Nipple discharge Cardiovascular: ___ Chest pain ___ Palpitations Gastrointestinal: ___ Abdominal pain ___ Change in bowel habits Genitourinary: ___ Change in urination habits Musculoskeletal: ___ Joint stiffness ___ Muscle weakness Neurological: ___ Weakness in extremities ___ Passing out Psychiatric: ___ Anxiety ___ Depression Endocrine: ___ Excessive thirst ___ Hot flashes Hematology: ___ Abnormal bleeding ___ Blood clots Family History Please indicate below if your parents, siblings, child or grandparents have any of the following conditions by placing an ‘X’ by the condition and list the individual’s relationship to you: Condition Relationship (Father, Mother, Sibling, Child, Maternal or Paternal Grandparent) _____ Alcoholism or Drug dependency ___________________________ _____ Blood Disorders ___________________________ _____ Cancer ___________________________ _____ Diabetes ___________________________ _____ Heart Disease ___________________________ _____ Heart Attack ___________________________ _____ High Blood Pressure ___________________________ _____ Psychiatric disorder ___________________________ _____ Stroke ___________________________ _____ Other ___________________________ Social History Marital Status (Circle one): Single Married Widowed Divorced Please list current household members and their ages: _____________________________ ______________________________ ___________________________ _____________________________ ______________________________ ___________________________ _____________________________ ______________________________ ___________________________ If female, total number of pregnancies _________ Miscarriages _____ Terminations _____ Preterm Deliveries _____ Stillbirths _____ Adult History 2 Name ____________________________________________________ How many siblings? _________ Any siblings deceased? If yes, please list cause of death and age at death: __________________________________________________________________________________________ __________________________________________________________________________________________ Father: ___ Living ___ Deceased (Age at death) _____ Mother: ___ Living ___ Deceased (Age at death) _____ Are you currently employed or retired? ____________________________________ Do you currently use or have used tobacco products? ___ Yes ___ No If ‘Yes’ what type(s): _________________________________________________________________________ In what year did you start? ______________ Quit date if no longer using tobacco products? _______________ Do you currently use or have used any illicit drugs? ___ Yes ___ No If ‘Yes’ what type(s): _________________________________________________________________________ In what year did you start? ______________ Quit date if no longer using illicit drugs? _______________ Do you drink caffeine? ___ Yes ___ No If ‘Yes’ how much do you drink? Daily _________ Weekly _________ Do you exercise? ___ Yes ___ No If ‘Yes’ how many times a week do you exercise? ______________________ What type of exercise do you do? _______________________________________________________________ Do you currently feel safe in your home? ___ Yes ___ No If ‘No’ please explain why? ____________________________________________________________________ __________________________________________________________________________________________ Medications Clearly list all medications you take including prescriptions, over the counter, vitamins, herbs, birth control etc. (use additional space at end if needed) Name of Medication Dosage How often do you take? (Ex: 2 times a day or every other day) _________________________________ _________________ _______________________________ _________________________________ _________________ _______________________________ _________________________________ _________________ _______________________________ _________________________________ _________________ _______________________________ _________________________________ _________________ _______________________________ _________________________________ _________________ _______________________________ _________________________________ _________________ _______________________________ _________________________________ _________________ _______________________________ _________________________________ _________________ _______________________________ _________________________________ _________________ _______________________________ Adult History 3 Surgical/Procedure History Please list any surgeries or procedures and the dates below (use additional space at end if needed): Surgery/Procedure Date __________________________________________________________ _______________________________ __________________________________________________________ _______________________________ __________________________________________________________ _______________________________ __________________________________________________________ _______________________________ __________________________________________________________ _______________________________ Do you or any family member have complications with anesthesia? ___ Yes ___ No Have you ever been told to take antibiotics before surgery? ___ Yes ___ No If ‘Yes’ why? ________________________________________________________________________________ Health Maintenance Please indicate the last date you had the followed test and vaccines: Bone Density Study __________________________ Colonoscopy ____________________________ Pap Smear _________________________________ Foot Exam ______________________________ Mammogram ________________________________ Prostate Exam ___________________________ Cholesterol _________________________________ Tetanus Shot ____________________________ Flu Shot ___________________________________ Pneumovax _____________________________ Hepatitis B _________________________________ Do you have a signed Do Not Resuscitate form? ___ Yes ___ No Do you have a Living Will? ___ Yes ___ No Do you have a Durable Power of Attorney for Healthcare? ___ Yes ___ No Please list any other concerns or conditions that would affect the care we provide you (ex. Hearing loss) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Adult History 4
