PATIENT HISTORY WORKSHEET

Please complete this entire 4 page form to allow us to update your prior information into our shared Electronic Medical Record

Gender: G Male G Female

Phone: Home: (_____)____________ Cell: (_____)____________ Work: (_____)____________

MEDICATIONSList any medications you take, prescription and nonprescription, and their dosage: G No medications

Medication

1. ____________________________________

2. ____________________________________

3. ____________________________________

4. ____________________________________

5. ____________________________________

6. ____________________________________

7. ____________________________________

8. ____________________________________

Dose

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Preferred Pharmacy

Pharmacy: ___________________________________ Phone Number: ___________________________________

Address: _____________________________________ City: ____________________________________________

ALLERGIES & REACTIONS Please list any significant reactions you have to medications or foods: G None Medications: Latex: Aspirin: IV Contrast: Penicillin: Insect Stings: Sulfa (Bactrim): Food Reactions: Others:

For Office Use Only: Form to be SHREDDED after abstraction. Not for scanning into Med Rec

Rev.12/11 Page 1 of 4

Full Name: Address: City, State, Zip: Date of Birth:

Date of Service:

PATIENT HISTORY WORKSHEETPAST MEDICAL HISTORY

Rev.12/11 Page 2 of 4

X DISEASE YEAR X DISEASE YEAR X DISEASE YEARAlcohol Dependence Depression Liver DiseaseAllergies Diabetes Type I Low Blood PressureAnemia Diabetes Type II Low Blood SugarAngina Diarrhea, Chronic Migraine HeadachesAnxiety Disc Disease (spine) ObesityArthritis Drug Abuse or Addiction OsteoporosisAsthma Emphysema / COPD PalpitationsBlood Clots Gallbladder / Stones Reflux (GERD)Broken Bones Goiter, Neck Rheumatoid ArthritisCancer (including type): Gout Sciatica

Headache Seizures/EpilepsyHeart Attack Sleep Apnea (OSA)

Celiac Disease Heart Disease (other): Stomach UlcerChronic Back Pain Heart Failure Stroke (CVA)Chronic Blood Thinner Use Hepatitis Throid Disease (high)Chronic Bronchitis High Blood Pressure Thyroid Disease (low)Chronic Fatigue Syndrome HIgh Blood Sugar Tinnitus (ear ringing)Chronic Hepatitis High Cholesterol TubculosisChronic Kidney Disease Insomnia UlcersChronic Neck Pain Irregular Heart Rhythm Other:Chronic Pain Irritable Bowel SyndromeChronic Sinusitis Kidney StonesCirculatory Disease Other Kidney Disease:Colitis

SURGICAL HISTORYPlease check all that apply. Date Date Date

G Angioplasty—Heart Balloon ____________ G Gallbladder _____________ G Liver biopsy _____________G Angioplasty w/ Stent ____________ G Colon removal _____________ G Bone Fracture surgery _____________G Appendectomy ____________ G Colostomy (bag) _____________ (pins &/or plates-ORIF) G Knee Scope surgery ____________ G Gastric bypass _____________ G Pacemaker _____________G Back surgery ____________ G Hernia repair _____________ G Small bowel removal _____________G Coronary Artery Bypass Graft ____________ G Hip replacement _____________ G Thyroid removal _____________G Carpal Tunnel release ____________ G Knee replacement _____________ G Tonsillectomy _____________G Cataract extraction ____________ G LASIK vision surgery _____________

G Other: ________________________________________________________ _____________

Female Surgical History Date Date

G Bilateral Tubal Ligation ____________ G Hysterectomy Partial ____________G Breast biopsy ____________ (Cervix & uterus, left tubes and ovaries) ____________G Breast enlargement or reduction ____________ G Total Hysterectomy—Abdominal cut + ovaries ____________G Breast cancer surgery (Mastectomy) ____________ G Vaginal Hysterectomy—Uterus only ____________G Cesarean section ____________ Uterus and Ovaries ____________G D & C (Dilation and curettage) ____________ G Uterus Fibroid removal (Myomectomy) ____________G Other: _____________________________ ____________

Male Surgical History Date Date

G Prostate biopsy ____________ G Vasectomy ____________G TURP (Trans-Urethral Resection of the Prostate) ____________ G Other: __________________________________ ____________

Full Name: Address: City, State, Zip: Date of Birth:

Date of Service: Please indicate if you have ever experienced any of the following conditions. Please include the date of onset.

FAMILY HISTORY

If ADOPTED with no known biological family  information (skip to next page) Otherwise, please fill in all that apply to your  “blood relatives” 

Common Family Diseases Feel free to add AGE @ time of diagnosis for 

each family member (if known)

PARENTS  SIBLINGS Other Family:  Grandparents Aunts / Uncles 

Mother Father Sisters Brothers # Affected Age: Now or (At Death) 

[i.e., 75 or (75) =deceased] Only 1 2 or

more Alcoholism  Allergies  Alzheimer’s 

Arthritis (Osteo­)  Asthma 

Attention Deficit (ADD/ADHD)  Blood Diseases 

Cancer(s) Which Type(s)?: 

Depression  Developmental Delays   

Diabetes    Eczema   

Hearing Deficiency    Heart Attacks—(before age 65) (CAD)    High Blood Pressure (Hypertension)    High Cholesterol (Hyperlipidemia)   

Irritable Bowel Syndrome    Kidney disease    Learning Disability    Mental Illness   

Migraine Headaches    Obesity   

Osteoporosis    Peripheral Vascular Disease (PVD)   

Seizures   

OTHER:  Family History of:  Abuse (any kind)  Anemia   Anxiety  Atopic Dermatitis  Bipolar disorder 

 Birth Defects  Blood Clots    Celiac   Colon Polyps  COPD­ Emphysema 

 Crohn’s disease  Genetic diseases   Joint Problems  Mental Retardation  Reflux (GERD) 

 Schizophrenia   Substance Abuse  Sudden Death  Thyroid   Ulcerative Colitis 

Abstractor Instructions: Select “Family H/O” if not sure of which family member had the disease. Type it in

Full Name: Address: City, State, Zip: Date of Birth:

Date of Service:

 Stroke (CVA) 

Other: 

SOCIAL HISTORY Family Status 

Marital Status:     Single     Divorced X ___    

 Separated   Widowed X___ 

Married—Current Marriage #:___      

Spouse Name: ______________________________ 

(Names & Ages):             

Sons:              Daughters: 

 Employment 

 Status:  Retired  Full‐Time  Part‐Time  Unemployed  Other:  _____________________________ 

__________________________  __________________________Name of Employer (Company Name)  Occupation 

Education                   Religion/Spirituality 

Highest level completed: __________________  Do you have a religious affiliation?____________________  Current School (if applicable):        Is religion/spirituality important in your life?             Y    N 

              Would blood transfusion be an option for you?        Y    N    

 Habits      

TOBACCO USE?  Yes    Never  Former     Year Quit?  _________       Total Years smoked?  __________ 

  Packs per Day?: ___________  Packs (or cans/pouches) per day?   ______________________

  Other Tobacco units per day (cans, cigars, etc)?  ____________________________________________________________________   Units per day? ______________________ 

    # of Years used?________________  

 Year Quit?  ___________ 

CAFFEINE USE?  Type & Amount: 

 Yes  No          Coffee:_____        Tea:_____         Soda:_____       

  Chocolate:_____ 

ALCOHOL USE?                      Yes                   No           Former:  Year Quit? _______          Type?  _______________________________  How much per week?  _______________________________________________   Amount?______________________________ 

    Last Drink?   _______________________________________________________ 

 Advance Directives 

  

Rev. 4/11    Page 4 of 4 

      None               Do Not Resuscitate               Living Will               Durable Power of Attorney for Health Care                

       Name of Health Care Proxy:  ___________________________________________ 

Full Name:Address: City, State, Zip: Date of Birth: Date of Service: