"Patient History Template - Corridor Primary Care"

ADVERTISEMENT
ADVERTISEMENT

Download "Patient History Template - Corridor Primary Care"

431 times
Rate (4.5 / 5) 29 votes
Corridor Primary Care, P.A.
512-396-1000
Patient History
Name (Please print): ______________________________ Age: _______ Date of Birth: _____________
I.
SOCIAL HISTORY
A. Marital Status: (Check one)
Single
Married: How long? _______
Widowed: When? ________
Divorced: When? ________
B. Children: (If any)
Name
Age
Residence (City/State)
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
C. Occupation: __________________________ Are you disabled? Yes ___ No ___
D. Education: (Last grade attended) _______________________________
E.
Religious preference: _______________________________________
F.
Hobbies/ Interests: _________________________________________
II.
HABITS
A. Smoking:
Never Smoked
Current Smoker Number of packs per day: ______ Number of years smoked: _____
Former Smoker Age you quit: _______
Number of years smoked: _____
B. Alcohol Use:
How much per week? ___________________
For how long? _________________
C. Other drugs: (Street drugs) _______________________________________________
D. Exercise:
Do you exercise routinely? Yes ____ No ____
What type of exercise? __________________________________________________
III.
MEDICAL HISTORY
A. Medication Allergies _____________________________________________________
B. Surgical History (Please list all operations and approximate date of each)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
C. Injuries (Please list all serious INJURIES, CONCUSSIONS OR FRACTURES)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
-Continued on other side-
Corridor Primary Care, P.A.
512-396-1000
Patient History
Name (Please print): ______________________________ Age: _______ Date of Birth: _____________
I.
SOCIAL HISTORY
A. Marital Status: (Check one)
Single
Married: How long? _______
Widowed: When? ________
Divorced: When? ________
B. Children: (If any)
Name
Age
Residence (City/State)
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
C. Occupation: __________________________ Are you disabled? Yes ___ No ___
D. Education: (Last grade attended) _______________________________
E.
Religious preference: _______________________________________
F.
Hobbies/ Interests: _________________________________________
II.
HABITS
A. Smoking:
Never Smoked
Current Smoker Number of packs per day: ______ Number of years smoked: _____
Former Smoker Age you quit: _______
Number of years smoked: _____
B. Alcohol Use:
How much per week? ___________________
For how long? _________________
C. Other drugs: (Street drugs) _______________________________________________
D. Exercise:
Do you exercise routinely? Yes ____ No ____
What type of exercise? __________________________________________________
III.
MEDICAL HISTORY
A. Medication Allergies _____________________________________________________
B. Surgical History (Please list all operations and approximate date of each)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
C. Injuries (Please list all serious INJURIES, CONCUSSIONS OR FRACTURES)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
-Continued on other side-
D. Medical History: Indicate any of the following that apply to the patient now or in the past.
Reaction to Immunizations
Heart Attack
Reaction to Anesthesia
Heart Murmur
Diabetes
High Blood Pressure
Thyroid Disease
Vein Clots
Cancer
Rheumatic Fever
Radiation Treatments
Heart Rhythm Problems
Blood Transfusion since 1977
Ulcers
Positive AIDS (HIV) test
Change in Bowel Habits
Changes in moles
Gall Bladder Problems
Unusual weight change past yr
Liver Disease
Arthritis
Hepatitis
Gout
Cholesterol
Strokes
Urine Incontinence
Tremor
Kidney Stones
Loss of Consciousness
Impotence
Seizures/ Epilepsy
Infection of Testicles, Prostate
Migraine Headaches
Infection of Tubes, Ovaries or
Use of Glasses or Contacts
Uterus
Cataracts
Abnormal Pap Smear
Glaucoma
Venereal Disease
Tuberculosis
Vasectomy
Asthma
Tubal Ligation
Depression
Hernias
Memory Impairment
Breast Lumps or Biopsies
Abnormal Mammogram
IV.
Medications: Please list all medications you are taking and dosages.
__________________________________________________________________________________
__________________________________________________________________________________
V.
Family History: Please list anyone in your family who has (had):
Cancer (Types) _______________________
Rheumatoid Arthritis _______________________
Heart Attack _________________________
Diabetes ________________________________
Stroke ______________________________
Problems similar to patient’s _________________
High Blood Pressure ___________________
_________________________________
_____________________________
Other ___________________________________
VI.
Women Only
Date of last menstrual period ____________
How many times have you been pregnant? _____
Age your periods began ________________
Number of deliveries: Vaginal ___ C-Section ____
Are your periods regular? Yes
No
Any
Tubal Pregnancies?
Yes
No
Are your periods Heavy Moderate Light
Miscarriages
Yes
No
Are your cramps Severe Mild None
Stillbirths
Yes
No
Date of last Pap smear _________________
Abortions
Yes
No
Date of last mammogram _______________
Complications with pregnancies?
Yes No
Do you check your breasts monthly? Yes No
Any abnormal vaginal discharge?
Yes No
To the best of my knowledge the statements and answers on this form are true, complete and correct.
____________________________________________________________
__________________________________________________
Patient or Guardian’s signature
Date
Please return to receptionist or nurse when completed and signed. Thank you.
Page of 2