SUSAN REICHERT, MD

HANDS ON HEALTHCARE

125 NW GREELEY AVENUEPATIENT HEALTH HISTORY

BEND, OREGON 97701

541-419-8743

Patient Name: ______Today’s Date: ______

Thank you for choosing to care for your health with me. I’d like to know as much about you as you are comfortable sharing. Please answer the questions below as completely as you are able.

Presenting Complaint: (Please describe why you are here today.)

What bothers you the most? ______

Specific location of the problem ______

Does symptom change or move? ______How? ______

Severity (rate on scale of 1 – 10 with 10 = most severe) ______

Quality/ characteristics: ______

(for example, for pain, is it sharp, burning, ache-y, etc?)

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Is it worse at a certain time of day? Explain. ______

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How long have you had this?______Ever had it before? ______

How did it start? ______

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What makes it better? ______Worse?______

What have you tried for this problem and how has that worked? ______

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Other health care providers seen for this problem: ______

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Please describe any HOSPITALIZATIONS and SURGERIES you have had:

Reason for HOSPITALIZATION or SURGERYYour age at that time

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Have you experienced any MAJOR TRAUMA – for example, accidents, injuries, fractures, burns, ingestions or poisonings, inflicted injuries?

Describe TRAUMAYourage at time of TRAUMA

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List ALL MEDICATIONS, SUPPLEMENTS AND REMEDIES you are CURRENTLY TAKING:______

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Please name ALL MEDICATIONS to which you are ALLERGIC:

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Dietary intolerances or food allergies:______

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OTHER ALLERGIES (Please also state if you have a sensitivity to perfumes or scents):

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REVIEW OF SYSTEMS

Please check those symptoms, conditions or experiences you have now or have had as a significant, chronic or recurrent problem in the past. We can discuss details in person.

Now / Past / Now / Past / Now / Past
General / Cardiovascular / Digestive
Substantial weight change / Heart murmur / Abdominal pain
Fatigue / Chest pain or angina / Nausea
Fever / High blood pressure / Vomiting
Headaches / Low blood pressure / Bloating / Excess gas
Dizziness, vertigo or fainting / Swelling of ankles / Diarrhea
Lack of energy / Poor circulation / Constipation
Congenital problemor condition / Heart palpitations / Bloodyormucous in stools
Chills or sweats / Irregular heart rate / Black or tarry stools
Difficulty sleeping / Varicose veins / Hemorrhoids
Anemia / Other heart problem / Anal itching or pain
Blood transfusion / Jaundice
Breast lump /discharge / Chest / Respiratory / Change in appetite
Cancer -- any type / Persistent cough / Loss of bowel control
AIDS / Coughing up blood / Gall bladder probs.
Neurologic / Wheezing/asthma / Endocrine
Nervousness/anxiety / Shortness of breath / Diabetes
Memory loss/forgetfulness / Pneumonia / Hormone or gland problem
Significant head injury / Excess thirst or urination
Seizures / Heat or cold intolerance
Numbness or tingling / Eyes & Ears / Thyroid condition
Paralysis / Blurred or double vision
Tremors / Change in ability to see / Nose, Mouth, Throat
Skin / Eye pain, disease or injury / Hay fever
Skin condition or rash / Wear glasses/contacts / Sinus problems
Itching / Visual flashes or halos / Nosebleeds
Hives / Hearing loss or
ringing in ears / Hoarseness
Bruise easily / Sore throat
Change in moles / Ear pain or injury / Difficulty swallowing
Sores won’t heal / Ear infections or discharge / Mouth sores
Scars / Bleeding gums

REVIEW OF SYSTEMS (CONT.)

Please continue to check those symptoms, conditions or experiences you have now or have had as a significant, chronic or recurrent problem in the past. We can discuss details in person.

Now / Past / Now / Past / Now / Past
Psychological/Social / Musculoskeletal / Genitourinary (cont)
Developmental delay / Jaw clicking or locking / Females:
Learning disorder / Neck or back pain / Pelvic pain
Attention deficit
and/or hyperactivity / Muscle pain, weakness / Vaginal discharge
Anxiety or panic attacks / Joint pain, stiffness, swelling, injury / Serious gyn condition
Depression / Change in periods
Problematic mood swings / Genitourinary / Heavy or painful periods
Suicidal thoughts or actions / Painful urination / Age when pregnant first time
Diagnosed mental health condition / Blood in urine / # of premature births
Problems in school / Frequent urination / # of term babies born
Mental health counseling / Incontinence/wetting / # of miscarriages or abortions
Addiction of any kind / Urgency to urinate / Symptoms of menopause
Spent time living in foster care / Kidney stones / Age periods stopped
Experienced child abuse, sexual abuse or domestic violence / Sexually transmitted disease / Males:
Eating disorder / Genital lesions/ warts / Penis or testicle pain or injury
Painful intercourse / Bleeding, discharge. Sores on / from penis
Sexual difficulty / Prostate problems

In addition to those mentioned above, if there are ANY OTHER HEALTH PROBLEMS you have had in the past or are now experiencing, please comment on them here.

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HABITS THAT AFFECT YOUR HEALTH:

How often? / How much? / How long doing this? / How does it benefit you? / Is it a problem for anyone?
Exercise
Dieting
Dietary supplements
Work
Sleep
TV
Other “screen” time
Cigarette smoking
Other tobacco use
Drink alcohol
Caffeine intake
Prescription medication
Recreational drugs – non-prescription or “street” drugs
Stress
Meditation
Please list other habits:

Please describe any recent or ongoing STRESSES in your life.

Examples: traumas, life changes, job changes or difficulties, stresses at home, with significant others, major challenges -- personal, social, emotional, professional, ethical, etc.

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How would you rate your current overall stress level?

(1= little or no stress, 10 = maximum stress) ______

SIGNIFICANT FAMILY HEALTH HISTORY

Please check if any of your close relatives (your parents, grandparents, siblings or children) have any of the following:

YES / YES / YES
Heart disease / Seizures/ epilepsy / Bleeding problems
Heart attack before age 50 / Mental health disorder / Serious childhood disease or ailment
High blood pressure / Suicide / SIDS
Cancer/ tumors / Breathing problems e.g. asthma / Death at a young age
Other serious health problems (please list)

Describe any concerns you have about your children or other family members.

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TREATMENT GOALS: Describe what you would like to gain from our work together. How are you hoping to benefit from coming to see me for care?

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Please list here ANYTHING ELSE you would like me to know to best address your health or any matter you would like to be sure we make time to discuss.

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SUSAN REICHERT, MD

HANDS ON HEALTHCARE

125 NW GREELEY AVENUE

BEND, OREGON 97701PATIENT REGISTRATION

541-419-8743Welcome!

Today’s Date: ______

Name (please print): ______Birthdate: ______

Signature: ______Age: ______Gender: F ___ M ___

Home Address: ______

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City StateZip

Mailing Address:______

(if different)

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City StateZip

*** PLEASE CIRCLE BEST NUMBER TO REACH YOU DURING THE DAY ***

Home phone: ______Work phone: ______

Cell or other phone: ______Email address: ______

Occupation: ______Employer: ______

Years of school completed: ______If a student now, name of school: ______

Single ___ Married ___ Separated ___ Divorced ___ Widowed ___ Number of children: ______

Name of spouse/ partner (If a minor, parent/guardian) ______

Emergency contact person: ______

Relationship to you: ______Phone number(s): ______

Primary care physician: ______

Who referred you to this practice? ______

Hands on Healthcare – Susan Reichert, MD Patient Health History 1

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