Last Name
First Name
Middle Name
Gender
MaleFemale
DOB
Marital Status SinglePartneredMarriedSeparatedDivorcedWidowed
Phone Number
Previous or referring doctor
Date of last physical exam
Childhood illness
MeaslesMumpsRubellaChickenpoxRheumatic FeverPolio
Immunizations and dates:
Tetanus
[conditional conditional-638-Tetanusdate]
[/conditional]
Pneumonia
[conditional conditional-190-Pneumoniadate]
Hepatitis
[conditional conditional-289-Hepatitisdate]
Chickenpox
[conditional conditional-500-Chickenpoxdate]
Influenza
[conditional conditional-803-Influenzadate]
MMR (Measles, Mumps, Rubella)
[conditional conditional-498-MMR]
List any medical problems that other doctors have diagnosed
Year
Reason
Hospital
Have you ever had a blood transfusion?
YesNo
Name the drug
Strength
Frequency Taken
Reaction you had
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.
Sedentary (No exercise)Mild exercise (i.e., climb stairs, walk 3 blocks, golf)Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Are you dieting?
[conditional conditional-363-Ifyes]
If yes, are you on a physician prescribed medical diet?
Rank salt intake
HiMedLow
Caffeine
NoneCoffeeTeaCola
# of cups/cans per day?
Do you drink alcohol?
[conditional conditional-531-Ifyeswhatkind]
If yes, what kind?
How many drinks per week?
Are you concerned about the amount you drink?
Have you considered stopping?
Have you ever experienced blackouts?
Are you prone to “binge” drinking?
Do you drive after drinking?
Do you use tobacco?
Cigarettes –pks./day
Chew - #/day
Pipe - #/day
Cigars - #/day
# of years
Or year quit
Do you currently use recreational or street drugs?
Have you ever given yourself street drugs with a needle?
Are you sexually active?
[conditional conditional-617-tryingforapregnancy]
If yes, are you trying for a pregnancy?
[conditional conditional-60-Ifnottrying]
If not trying for a pregnancy list contraceptive or barrier method used:
Any discomfort with intercourse?
Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?
Do you live alone?
Do you have frequent falls?
Do you have vision or hearing loss?
Do you have an Advance Directive or Living Will?
Would you like information on the preparation of these?
Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?
Age
SIGNIFICANT HEALTH PROBLEMS
MF
Is stress a major problem for you?
Do you feel depressed?
Do you panic when stressed?
Do you have problems with eating or your appetite?
Do you cry frequently?
Have you ever attempted suicide?
Have you ever seriously thought about hurting yourself?
Do you have trouble sleeping?
Have you ever been to a counselor?
[conditional conditional-757-womenonly]
Age at onset of menstruation:
Date of last menstruation:
Period every ___ days
Heavy periods, irregularity, spotting, pain, or discharge?
Number of pregnancies
Number of live births
Are you pregnant or breastfeeding?
Have you had a D&C, hysterectomy, or Cesarean?
Any urinary tract, bladder, or kidney infections within the last year?
Any blood in your urine?
Any problems with control of urination?
Any hot flashes or sweating at night?
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?
Experienced any recent breast tenderness, lumps, or nipple discharge?
Date of last pap and rectal exam?
[conditional conditional-9930-menonly]
Do you usually get up to urinate during the night?
If yes, # of times _____
Do you feel pain or burning with urination?
Do you feel burning discharge from penis?
Has the force of your urination decreased?
Have you had any kidney, bladder, or prostate infections within the last 12 months?
Do you have any problems emptying your bladder completely?
Any difficulty with erection or ejaculation?
Any testicle pain or swelling?
Date of last prostate and rectal exam?
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
Skin
Chest/Heart
Recent changes in:
Head/Neck
Back
Weight
Ears
Intestinal
Energy level
Nose
Bladder
Ability to sleep
Throat
Bowel
Other pain/discomfort
Lungs
Circulation
Patient Printed Name
Date
Patient Signature
Do you have Guardian ?
[conditional conditional-266-GuardianPrintedName]
Guardian Printed Name
Guardian Signature
Guardian / Legal Representative