Gainesville Family Practice

GAINESVILLE FAMILY PRACTICE

PERSONAL HEALTH HISTORY

Name: ______Date: ______

PLEASE CHECK EITHER: Y or  N (please explain any yes answers)

PAST HISTORY

Childhood (infancy through teens)Adult (age 20 to present)

Serious Illness? Y  N______Serious Illness?  Y  N ______

Surgery?  Y  N______Surgery? Y  N ______

Hospitalizations? Y  N ______Hospitalizations? Y  N______

Allergies? Y  N ______Allergies? Y  N ______

FAMILY HISTORY (Parents, Siblings, Grandparents, Aunts, Uncles)

Heart Disease?  Y  NDiabetes?  Y  NCancer?  Y  N

High Blood Pressure?  Y  NStroke?  Y  NDepression?  Y  N

SYSTEM REVIEW

Respiratory Tract

Chronic cough?  Y  NCough Blood?  Y  NEasily short of breath?  Y  N

Sinus trouble?  Y  NAllergy Shots?  Y  NChest Pain?  Y  N

Heart and Blood Vessels

Chest pain?  Y  NPrior Heart Attack?  Y  NLeg pain with walking?  Y  N

Palpitations?  Y  NFluid in feet?  Y  N

Gastrointestinal Tract

Heartburn?  Y  NUlcers?  Y  NHiatal Hernia?  Y  N

Chronic nausea?  Y  NCramping?  Y  NPoor Appetite?  Y  N

Chronic diarrhea?  Y  NBlood in stools?  Y  NPain in abdomen?  Y  N

Change in stools?  Y  N

Skins and Nails

Chronic rash?  Y  NNew moles?  Y  NFrequent sun exposure?  Y  N

Neurologic System

Frequent headaches?  Y  NMigraines?  Y  NNumbness?  Y  N

Fainting spells?  Y  NDouble vision?  Y  NSeizures in past?  Y  N

Skeletal System

Joint pains?  Y  NBroken bones?  Y  NSprained joints?  Y  N

Back pain?  Y  NArthritis?  Y  N

Questions for MEN

Painful urination?  Y  NDifficult urination?  Y  NBlood in urine?  Y  N

Discharge from penis?  Y  NNighttime urination?  Y  N(if yes, how many times per night?) ______

Sexual difficulty?  Y  N

PLEASE TURN PAGE AND COMPLETE BACK SIDE

Questions for WOMEN

Painful urination?  Y  NDifficult urination?  Y  NPainful menses?  Y  N

Irregular menses?  Y  NBirth Control Pills?  Y  NNumber of Pregnancies? ______

Number of children? ______Vaginal Discharge?  Y  NDate of last PAP? ______

Age of onset of menses? ______Age at onset of Menopause? ______Hot flashes?  Y  N

Sexual difficulties?  Y  NUterus removed?  Y  NUterus removed?  Y  N

General Questions

Weight loss?  Y  NWeight gain?  Y  NNo interest in eating?  Y  N

Difficulty sleeping?  Y  NAlways tired?  Y  NAlways feel cold?  Y  N

What was your highest weight? ______When? ______

OCCUPATIONAL HISTORY

Current occupation? ______How long? ______

Previous occupations? ______

Any job-related injury?  Y  NAny chemical or fumes exposure?  Y  N

Any job disability?  Y  N

SOCIAL HISTORY

Habits

Smoker?  Y  NHow much? ______When started? ______When stopped? ______

Do you drink alcohol?  Y  N If yes, (Please circle): Beer Wine Liquor Cordials

Please circle the level of alcohol consumption:None Occasional Weekends Daily Heavy

Have you used illegal drugs?  Y  N

Have you had a sexually transmitted disease?  Y  N

Do you think you may have any activity that puts you at risk of HIV/AIDS?  Y  N

IS THERE ANY ADDITIONAL HEALTH HISTORY? ______

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