North Franklin Internal Medicine & Pediatrics Clinic: Adult New Patient Questionnaire
Patient Name: Date of Birth: _____________
Spouse/Partner: ______________________________________________________________Height: Weight: ___________
Children: Name Male/Female Age: Name Male/Female Age: _____
Name Male/Female Age: Name Male/Female Age: _____
Name Male/Female Age: Name Male/Female Age: _____
Illnesses/Medical Problems-Past & Present (e.g. seasonal allergies, heart disease, hypertension)
|
Date of Onset
|
Operations or Injuries
|
Date
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Current Medications (include over-the-counters, supplements, herbals, etc.)
|
Dosages
|
Current Medications(continued)
|
Dosages
(continued)
|
Drug Allergies and/or Reactions
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Immunizations: Tetanus Influenza Pneumovax (Pneumonia)
(Date of last shot/test) TB Test: Hepatitis A: Hepatitis B: __________ Measles: Rubella: Varicella (Chickenpox):___________
When were your most recent HEALTH MAINTENANCE screening tests?
Lipid (cholesterol): Results: PSA (prostate cancer): Results: _________
Colonoscopy/Sigmoidoscopy/stool blood test: ______________ Results: __________________
Bone Density Test: Results: Mammogram: Results: _____________
Ever Abnormal Results: Details: _____________________________________
Family History
|
Age
|
Deceased?
|
Illnesses and/or Cause of Death
|
Are any of the following illnesses in the family?
Heart Attacks
Cancer
Strokes
High Cholesterol
High Blood Pressure
Diabetes
Allergies or Asthma
Seizures / Epilepsy
Mental Illness (Depression)
Kidney Disease
Breathing Problems
Birth Defects
Alcoholism
Bleeding / Clotting Problems
(FLIP FORM OVER)
|
Mother
|
|
|
|
Father
|
|
|
|
Brother/Sister
|
|
|
|
Brother/Sister
|
|
|
|
Brother/Sister
|
|
|
|
Brother/Sister
|
|
|
|
Child #1
|
|
|
|
Child #2
|
|
|
|
Child #3
|
|
|
|
Child #4
|
|
|
|
Mom’s Mom
|
|
|
|
Mom’s Dad
|
|
|
|
Dad’s Mom
|
|
|
|
Dad’s Dad
|
|
|
|
Patient Name: ______________________________________
Systems Review: Are you troubled by any of the following?
General YES NO
Unexplained Weight Loss or Gain Intestinal System (continued) YES NO
Excessive Thirst Heartburn
Excessive Fatigue Frequent Indigestion
Night Sweats / Frequent Fevers
Genitourinary System
Painful Urination
Passing Blood
Skin and Hair Poor Bladder Control
Any skin or Hair Problem Weak Urine Stream
Difficulty Hearing / Ringing in Ears Urination more than once a night
Problems with Teeth / Gums Unusual Vaginal Bleeding
Hay Fever / Seasonal Allergies / Rhinitis Discharge from penis or vagina
Nose problem
Hoarseness Skeleton and Joints
Trouble Swallowing Pain in Joints
Swelling in Joints
Heart and Lungs Morning Joint Stiffness greater than 30 minutes
Frequent Cough
Shortness of Breath Back Trouble
Coughing up Blood
Chest Pain / Pressure / Heaviness Nervous System
Wheezing Severe or Frequent Headaches
Chest Discomfort with Exercise Numbness of Hands and Feet
Irregular Heart Beat Uncontrollable Tension
Other Heart Trouble Increased Irritability
Ankle Swelling Feelings of Being “Blue”
Thoughts of hurting yourself or others
Intestinal System Memory Problems
Appetite Loss Loss of Coordination
Frequent Belching
Abdominal Pain Personal Problems
Frequent Nausea and Vomiting Problems with sexual relations?
Change in Bowel Habits Have you had psychiatric help?
Persistent Constipation Do you desire psychiatric help?
Frequent Diarrhea
Rectal Bleeding
Social History Other Concerns
Tobacco Use Caffeine Intake: None Coffee/ Tea: cups per day
Cigarettes Never Quit Date: Sodas: /day Chocolate: oz./day
Current Smoker packs/day #of years
Other Tobacco: Pipe Cigar Snuff Chew WEIGHT: Are you satisfied with your weight? No Yes
Are you interested in quitting? Yes No
DIET: How do you rate your diet? Good Fair Poor
Alcohol Use Do you take supplements? .
Do you drink alcohol? No Yes # drinks per week: _____ Do you drink 4 lg. glasses of milk daily or take CALCIUM supplements?
Type of alcohol? ____________________________ No Yes
Is your alcohol use a concern for yourself or others? No Yes
EXERCISE: Do you exercise regularly? No Yes
Drug Use What kind of exercise? .
Do you use any recreational drugs? No Yes How long (minutes) How often? .
Have you EVER used needles? No Yes If you do not exercise, why? .
Sexual Activity BIKE HELMET: Do you use a helmet? No Yes
Sexually Active: No Yes Not Currently
Birth Control Method: None Needed SEAT BELT: Do you use seatbelts consistently? No Yes
Have you ever had any sexual transmitted diseases? (STD’S) Do you feel safe at home? No Yes
No Yes Have you ever been ABUSED? No Yes
Are you interested in being screened for sexually transmitted Do you have a GUN in your home? No Yes
diseases (STD’S)? No Yes
FOR WOMEN ONLY FOR MEN ONLY
Ever had an abnormal pap smear? No Yes Have you had any of the following?
If yes, when? . Sore on penis No Yes
Are your periods irregular? No Yes Swelling or tenderness in scrotum No Yes
Do you bleed in between periods? No Yes Any problems with sexual function No Yes
Do you have an IUD? No Yes Any problems having children No Yes
When was your last period? . “Prostate Trouble” No Yes
How long between beginning of one period and the next? . Ever had a vasectomy No Yes
How many days do you flow? . Ever had an instrument passed into the bladder No Yes
Flow Amount: Very Little Moderate Heavy
Do'stlaringiz bilan baham: |