Download Medical History Form - South Georgian Bay Community Health Centre

Medical Questionnaire
Questionnaires will be kept confidential.
Patient’s full name:
Preferred name:
Do you currently have a family physician? _____ If yes, name & location:
For women:
For men:
_____ Number of pregnancies
Delivery Mode:_______________
_____ Number of children_____
Prostate disorders:
Testicular disorders:
Age at start of menstruation _______
Age at start of menopause: ______
HRT ______________ # yrs: ________
Have you ever breastfed? Y/ N
_____ Number of children
Uterine Disorders:
Hysterectomy: Full or Partial
Preventative Health Screening (age 50+ or family
Date of Last Pap Smear:
History of Abnormal Pap Smear: Y /N
history)
Preventative Health Screening (age 50+ or family history)
Date of last Mammogram:
Due for Mammo:
Date of last FOBT/colonoscopy:
Y/N
Mammo Req Given: Y / N
Due for FOBT: Y / N FOT given: Y / N
Declined FOBT: Y / N
Colorectal Cancer: Date of last FOBT/colonoscopy:
Due for FOBT: Y / N
FOBT given: Y / N
Declined FOBT:
Allergies
Allergies to medications: (specify type of reaction)
Other known allergies, include reactions:
Surgical History
List surgeries and dates (include tonsils, adenoids, appendix, etc):
Have you had a reaction to anaesthesia?
Have you been told you are difficult to intubate?
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I003 – SGBCHC – 1 HOUR INTAKE PT QUESTIONNAIRE - DRAFT
Medical problem:
Head, eye, ear, nose, throat
Angina/Angioplasty/Cardiac/CAD
Hypertension
High cholesterol
Stroke/TIA
Vascular disorders
Clotting/bleeding disorder
Person al medical history
Anemia
Asthma/emphysema/COPD/other lung
disorder
Gastrointestinal disorders
Liver disease – Hep A/B/C, cirrhosis
Kidney/bladder disorders
Arthritis
Osteoporosis/osteopenia
Chronic muscle/joint pain
Thyroid disease
Diabetes
Headaches/migraines
Neurological disorders
Psychiatric/mental health
Addictions
Dementia/ABI/cognition issues
Skin – eczema, psoriasis, other
Cancer type:
Diagnosis date:
Treatment:
Problem/Date of onset:
Immunization
Flu Shot: Y / N
(record for MSAA indicators)
Pneumococcal (age 65+): Y / N
Zostavax (age 55+): Y / N
Last Td/Tdp:
(one pertussis vaccine in adulthood
regardless of last Td)
Family History
List ALL family members & any illnesses. If deceased, indicate at what age & COD.
Mother:________________________________
Father: ________________________________
Sister(s): _______________________________
Brothers: _______________________________
______________________________________
______________________________________
Employment
Occupation/History:
Where are you employed?
If not working: □ Retired □ EI □ OW □ other:
Disability pension: CPP / ODSP / other:
Are you interested in volunteering with the SGBCHC?
□ No income
□ Yes
□ No
Relationship/Marital status:
Abuse:
Other SDM, POA-PC, POA-F:
Who do you live with?
Who is your support system?
Do you have in-home support? (CCAC, Red Cross, hospice, etc.)
Literacy:
Mental health issues:
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I003 – SGBCHC – 1 HOUR INTAKE PT QUESTIONNAIRE - DRAFT
Tobacco use:
Non-Smoker
Never Quit Date:
Years smoking:
cigs/day:
Quit attempts (dates):
On a scale of 1-10 how would you rate your motivation to quit smoking?
Not ready to quit
Ready to quit
Interest in quitting:
If yes, referred to smoking cessation group: □
Do you drink alcohol? __________ If yes, how many drinks per week? ________________________
Lifestyle
Type(s) of alcohol consumed:
Recreational drugs:
Gambling:
Transportation:
Do you exercise regularly? __________ Frequency: _______________________
Describe type(s) of activity:
Nutrition:
Mobility issues:
□ mobility aid used (e.g.: cane, walker, wheelchair):
Falls risk:
Have you had a fall in the past 12 months?
Have you had a near fall in the past 3 months?
Do you have a fear of falling?
*Yes to any, refer to falls prevention program*
Pharmacy:
Extended health benefit plan/ODSP/Trillium/Other:
Do you see any specialists? (Name and specialty):
Are you taking any medication(s) at this time?
Is it ok to leave information on your answering machine or with a spouse/person who answers the phone?
□ Yes
□ No
□ Sometimes
Details:
Are there any other health issues/concerns you would like to mention at this time:
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I003 – SGBCHC – 1 HOUR INTAKE PT QUESTIONNAIRE - DRAFT
Referral to programs:
Date:
 Chronic Disease/Pain Self Management Program
 Nutrition Programs
 Diabetes Education Workshops
 Mindfulness Meditation
 Nordic Pole Walking
 Fitness for Health
Signature: _________________________________
Date: __________________________