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Albany Community Health Clinic 920 E. Sheridan St., Suite A Laramie, WY 82070 (307) 460 – 9039 Email: [email protected] Patient Medical Information Initial Intake Full Name: Date of Birth: Reason for today’s visit: Current Medications Medication Example: Lisinopril Dose How Often 10 mg 1 a day Allergies to Medications (please circle) YES / NO Medication Dose If so, to what drug(s) and with what reaction(s): Past Medical History (Please √ only if you have a history of any of the following □ ADHD □ Alcohol Use Disorder □ Allergic Rhinitis □ Asthma □ Atrial Fibrillation □ Anemia □ Anxiety □ Autoimmune Disorder Revised 8/2015 How Often □ Bipolar Disorder □ Blood Transfusion □ Brain Tumor □ Cirrhosis □ Chronic Renal Failure □ COPD □ Colon Cancer □ Coronary Heart Disease □ Crohns Disease □ Stroke □ Depression □ Diabetes – Child/Insulin □ Diabetes – Adult Onset □ Diverticulitis/Diverticulosis □ DVT/Blood Clots in Legs □ Ear Infection Recurrent □ GI Bleed Upper □ GI Bleed Lower □ GERD (Reflux) □ Heart Failure □ Hemochromatosis □ High Cholesterol □ High Blood Pressure □ Hyperthyroidism □ Hypothyroidism □ Hepatitis, Type ____ □ Inflammatory Bowel Disease □ Irritable Bowel Syndrome □ Kidney Disease □ Kidney Stone(s) □ Liver Disease □ Metabolic Syndrome □ Heart Attack (MI) □ Neurologic Disorder __________________ □ Osteoarthritis □ Osteoporosis □ Pancreatitis □ Peripheral Vascular Disease □ Peptic Ulcer Disease □ Rheumatoid Arthritis □ Seizure Disorder □ Tuberculosis History □ Ulcerative Colitis □ UTI - Recurrent □ Valvular Heart Disease □ Varicose Veins/Phlebitis □ Abnormal Pap Smear Have you had any of the following Surgeries (Please √): □ AAA Repair □Abdominal Surgery, Type___________ □ Abd/Umbil Hernia Repair □ Amputation □ AV Fistula Creation □ AV Graft □ Aortic Valve Replacement □ Appendix Removal □ Breast Surgery □ Bronchoscopy □ C-Section □ CABG (Heart Bypass) □ Carotid Endarterectomy □ Carpal Tunnel □ Cataract □ Gallbladder Removal □ Colon Surgery □ Colostomy □ Craniotomy (Brain Surgery) □ Gastric Bypass □ Hemorrhoid Removal □ Hip Replacement □ Inguinal Hernia Repair Revised 8/2015 □ Knee Arthroscopy □ Knee Replacement □ Spine Surgery □ Lap Band-Gastric □ Breast Lump Removal □ Breast Surgery □ Mitral Valve Replacement □ Kidney Removal or Transplant □ Pacemaker □ Pain Injections □ Parathyroid Removal □ Lung Surgery □ Angioplasty □ Supra-pubic Catheter □ Rotator Cuff Repair □ Uterus and Ovary Removal □ Uterus Removal only □ Tonsil Removal □ Tubal Ligation (Female Tubes Tied) □Urinary Incontinence Surgery □ Vasectomy □ Anesthesia Problem – NO □ Breast Disease □ Breast Cancer □ Cervical Cancer □ Diabetes – Gestational □ Infertility □ RH Sensitized □ Uterine Anomaly Other Issues Not Listed: □ Anesthesia Problem - YES □ Cervical Spine Fusion □ Thoracic Spine Fusion □ Lumbar Spine Fusion □ Cervical Spine Laminectomy □ Thoracic Spine Laminectomy □ Lumbar Spine Laminectomy □ Kyphoplasty □ Surgical Complications NO □ Surgical Complications YES □ Post-op delirium Other Surgeries Not Listed: Do you have a Family History of any of the following? (Please √): □ Unknown □ Adopted □ Alcoholism □ Anemia □ Arthritis □ Anesthetic Complication □ Anxiety □ Asthma □ Birth Defects □ Bleeding Disorder □ Breast Cancer □ Colon Cancer □ Depression □ Diabetes □ Heart Disease □ Hypertension □ High Cholesterol □ Kidney Disease □ Lung Disease □ Migraines □ Osteoporosis □ Seizures □ Severe Allergies □ Stroke □ Thyroid Disease □ Other Cancer □ Angina □ Cervical Cancer □ Coronary Heart Disease<55 □ Coronary Heart Disease<65 □ Colon Cancer – Father □ Colon Cancer - Mother □ Growth/Development □ Lung Cancer □ Melanoma □ Ovarian Cancer □ Uterine Cancer □ Weight Disorder □ Other Medical Problems □ Endometriosis Other Issues Not Listed: Please check the boxes that apply to your Social situation: (Please √ /fill in/circle): □ Single □ Married □ Divorced □ Widowed/Widower □ Employed □ Retired □ Unemployed □ Disabled □ Occupation_____________ □ Live in Care Facility □ Live with ______________ Children? At home? ________ Grown? ___________ Religious Preference affecting care: (list)________________ Do you feel safe at home? _________ Medical Risk Factors (Please √ your answers to the following): Tobacco Use: □ Current Year Started: Cigarettes □ Yes □ No Amount Pk/Day: Cigars □ Yes □ No Amount #/Wk: Smokeless □ Yes □ No Amount Per Day: □ Quit Year Quit: Pack/Years: □ Never Passive Smoke Exposure: □ Yes □ No Illegal Drug Use: □ Yes □ No HIV High Risk Behavior: □ Yes □ No Caffeine Use (drinks/day): Alcohol Use: □ Yes □ No Type: Amount/day: Exercise: Times/week _____________ Seatbelt Use: □ 0% □ 25% □ 50% □ 75% □100% Sun Exposure: (circle one) Freq: Occas Rarely Remote Have you ever had: Colonoscopy □ Yes □ No If yes, when? _____________ (For women) Mammogram □ Yes □ No If yes, when? _____________ Pap Smear □ Yes □ No If yes, when? _____________ Review of Systems (Please √ only if you are currently suffering from any of the following): General □ Loss of appetite □ Chills □ Dizziness □ Fatigue □ Fever □ Continued Fever □ Headache □ Feeling Ill □ Sweats □ Night sweats □ Sleep disturbance □ Weight loss Eyes □ Blurring of Vision □ Double Vision □ Eye Irritation □ Discharge □ Vision Loss □ Eye Pain □ Eye swelling □ Droopy eyelid □ Sensitivity to light □ Redness □ Itching Ear/Nose/Throat □ Earache □ Ear discharge □ Ringing in the ears □ Decreased Hearing □ Nasal Congestion □ Nosebleeds □ Runny nose □ Hoarseness □ Difficulty swallowing □ Dry mouth □ Bleeding gums □ Swollen glands Cardiovascular □ Chest pain □ Palpitations □ Feeling faint □ Trouble breathing with exertion □ Shortness of breath-lying down □ Shortness of breath at night □ Peripheral edema □ Elevated blood pressure □ Decreased heart rate Respiratory/Breast □ Cough □ Difficulty breathing □ Shortness of breath □ Excessive sputum □ Coughing up blood □ Wheezing □ Chest pain □ Breast changes □ Breast lumps □ Nipple discharge Gastrointestinal □ Nausea □ Vomiting □ Cramps □ Diarrhea □ Bloody diarrhea □ Watery diarrhea □ Constipation □ Change in bowel habits □ Abdominal pain □ Blood in stool □ Black or tarry stool □ Jaundice □ Heart burn □ Urge to defecate Genitourinary □ Urinary incontinence □ Pain with urination □ Burning with urination □ Urinary frequency □ Urinary hesitancy □ Urinary urgency □ Urinary urgency at night □ Incomplete emptying □ Blood in urine □ Absence of menstrual period □ Heavy menstrual period □ Prolonged menstrual period □ Pelvic pain □ Abnormal vaginal bleeding □ Painful intercourse □ Vaginal discharge □ Vaginal sores □ Genital burning □ Genital itching □ Genital warts □ Anal discharge □ Anal sores □ Anal warts Musculoskeletal □ Back pain □ Joint Pain □ Leg pain □ Other pain-see comment □ Joint swelling □ Body aches □ Muscle aches □ Muscle cramps □ Muscle weakness □ Stiffness □ Recent Injury Dermatologic □ Rash □ Hives □ Redness □ Itching □ Dryness □ Suspicious lesions □ Athlete’s foot □ Rash on palms □ Rash on bottom of feet Neurologic □ Muscle impairment □ Weakness □ Numbness and tingling □ Seizures □ Slurred speech □ Feeling faint □ Tremors □ Vertigo □ Paralysis on both sides Psychiatric □ Depression □ Anxiety □ Memory loss □ Mental disturbance □ Suicidal ideation □ Homicidal ideation □ Hallucinations □ Paranoia □ Feeling stressed □ Hearing voices Endocrine □ Cold intolerance □ Heat Intolerance □ Excessive thirst □ Excessive Hunger □ Excessive urination □ Weight loss □ Weight gain Hematology □ Abnormal bruising □ Bleeding □ Enlarged lymph nodes Allergy □ Hives □ Swelling □ Hay fever □ Persistent infection □ HIV/STI exposure □ Other Issues Not Listed: