Health History Intake Form

Health History Intake Form

Your physician today:

 Garrett Chumney, MD Do you have a Living Will?  Yes  No

 Teressa Edenfield, ARNP

 Linda Deese, ARNP

Today’s Date: ______

Patient’s Name: ______

Date of Birth: ______Age: ______Gender:  Male  Female

Previous Primary Care Physician (if any): ______

Phone: ______Address: ______

Other Physician’s involved in your care: ______

______

Reason for visit today: ______

______

Allergies- (Medication/Food, indicate reaction): None

______

______

______

Medication List: (Please list name/dose/frequency if known)

______

______

______

______

______

______

Family History: (please indicate deceased or alive, medical issues and age)

Father: ______

Mother: ______

Siblings: ______

Grandparents: Maternal: ______

Paternal: ______

Calhoun Liberty Hospital Primary Care ClinicHealth History Intake Form1

Patient Name: ______DOB: ______

Habits:

Alcohol:  None Yes: How many drinks/day ______frequency/week ______what kind ______

Tobacco:  None Yes: Chew or Smoke? ______How many/day ______since ______

Caffeine:  None Yes: What kind? ______how many/day ______

Other recreational drugs:  None Yes: What kind ______How many/day ______

Do you drive? Yes No Do you always wear a seatbelt?  Yes  No

Do you exercise?  Yes  No If yes, how much? ______

Social History:

Work: Employed Unemployed  Retired Disabled

Current Occupation______Former Occupation ______

Marital Status:MarriedSingleDivorcedDomestic Partner

Sexual Preference:Men Women Both

Children (age): ______

Hobbies: ______

Sports: ______

Pets: ______

Other: ______

Past Surgical History (indicate date if known)

 None Bariatric Surgery______

 Cataracts______ Hysterectomy______

 Lasik ______ Endoscopy______

 Tonsillectomy ______ Colonoscopy______

 Thyroidectomy ______ Hernia______

 Adenoidectomy ______ Spinal Surgery______

 Coronary Bypass ______ Tubal Ligation______

 Cardiac Stents ______ Bladder Surgery______

 Pacemaker ______ Prostate surgery/resection______

 Heart Valve ______ C-Section______

 Gall Bladder ______ Orthopedic/joints______

 Appendectomy______

 Bowel/Stomach Resection ______ Other ______

 Hemorrhoidectomy______

HospitalizationsImmunizations History

______Tetanusdate: ______

______Flu date: ______

______Pneumonia 23 or 13date: ______

______

Physical History

Annual Physical Yes  No date: ______Physician: ______

Mammogram Yes  No date: ______Facility: ______

Bone Density Scan (Dexa) Yes  No date: ______Facility: ______

Calhoun Liberty Hospital Primary Care ClinicHealth History Intake Form2

Patient Name: ______DOB: ______

Past Medical History:

Headaches Yes  Nodate: ______

Stroke Yes  Nodate: ______

Seizures Yes  Nodate: ______

Pneumonia Yes  Nodate: ______

Diabetes Type: ______ Yes  Nodate: ______

Thyroid Disease Type: ______ Yes  Nodate: ______

Glaucoma Yes  Nodate: ______

Macular Degeneration Yes  Nodate: ______

Hearing Loss Yes  Nodate: ______

High Blood Pressure Yes  Nodate: ______

Blood Clots Yes  Nodate: ______

Pulm Emboli (lung clots) Yes  Nodate: ______

DVT (leg clots) Yes  Nodate: ______

Heart Burn, Reflux Yes  Nodate: ______

Stomach Ulcers Yes  Nodate: ______

Heart Disease Yes  Nodate: ______

Coronary Disease Yes  Nodate: ______

MI/Heart Attacks Yes  Nodate: ______

Congestive Heart Failure Yes  Nodate: ______

Atrial Fibrillation Yes  Nodate: ______

Angina Yes  Nodate: ______

Valve Disorder Yes  Nodate: ______

High Cholesterol Yes  Nodate: ______

Gastrointestinal Bleeding Yes  Nodate: ______

HepatitisA BC Yes  Nodate: ______

HIV/AIDS Yes  Nodate: ______

Chronic Wounds Yes  Nodate: ______

CancerType: ______ Yes  Nodate: ______

Urinary Tract Infections Yes  Nodate: ______

Incontinence Yes  Nodate: ______

Kidney Stones Yes  Nodate: ______

COPD (Emphysema, Bronchitis) Yes  Nodate: ______

Asthma Yes  Nodate: ______

Depression Yes  Nodate: ______

Bipolar Disorder Yes  Nodate: ______

Anxiety Yes  Nodate: ______

Fibromyalgia Yes  Nodate: ______

Chronic Fatigue Syndrome Yes  Nodate: ______

Arthritis Yes  Nodate: ______

Gout Yes  Nodate: ______

Osteoporosis Yes  Nodate: ______

Prostate Disease Yes  Nodate: ______

Breast Disease Yes  Nodate: ______

Erectile Dysfunction Yes  Nodate: ______

Other: ______

Calhoun Liberty Hospital Primary Care ClinicHealth History Intake Form3

Patient Name: ______DOB: ______

Review of Systems(  Yes or No for symptoms in past 6 months, Circle for symptoms TODAY)

Constitutional/Endocrine FEMALE Reproductive
 Yes  NoFever Yes  NoHot flashes

 Yes  NoChills Yes  NoBleeding after menopause

 Yes  NoWeakness/Fatigue Yes  NoExcessive menstrual bleeding

 Yes  NoWeight Loss Yes  NoUnusual vaginal discharge

 Yes  NoWeight GainAge at onset of menstruation ______

 Yes  NoInsomnia1st day of last menstruation ______

 Yes  NoSnoring Yes  NoMenstrual pain/cramps

 Yes  NoExcessive thirst Yes  NoSpotting between periods

 Yes  NoExcessive urinationLast PAP smear: ______Results:______

 Yes  NoCold or Heat intoleranceHistory of Abnormal PAP?  Yes  No if so, when ______

Total Pregnancies: ______

HEENT

 Yes  NoSore Throat

 Yes  NoStiff neck

 Yes  NoChange in your voiceCardiac

 Yes  NoSinus Drainage Yes  NoChest Pain

 Yes  NoSinus headache Yes  NoPalpitation

 Yes  NoNose Bleeds Yes  NoIrregular heartbeat

 Yes  NoEar ache/drainage Yes  NoExercise intolerance

 Yes  NoHearing Loss Yes  NoLeg Swelling

 Yes  Noringing in your earsOther: ______

 Yes  NoBlurred Vision/loss

 Yes  NoWear glasses/contactsRespiratory

 Yes  NoItchy/watery eyesYes  NoPersistent Cough

 Yes  NoDental problemsYes  NoCoughing up blood

Other: ______ Yes  NoWheezing

 Yes  NoCan’t breathe laying flat

GastrointestionalOther: ______

 Yes  NoNausea/vomiting

 Yes  NoDifficulty swallowingSkin

 Yes  NoHemorrhoids Yes  NoRashes/Hives

 Yes  NoDiarrhea Yes  NoSkin discoloration

 Yes  NoConstipation Yes  NoLesions/moles/warts

 Yes  NoBloody or Black Stools Yes  NoUlcers

 Yes  NoAbdominal pain Yes  NoItching

 Yes  NoHeart burn/indigestion Yes  NoNail Problem

 Yes  NoFrequent use of laxatives Yes  NoUnusual hair loss

Other: ______ Yes  Noeasy bruising

Other: ______

Urinary

 Yes  NoPain or burning with urinationPsych

 Yes  NoUrinary frequency (Night or Day) Yes  NoDepressed mood

 Yes  NoBlood in urine/ dark urine Yes  NoSuicidal thoughts/plans

 Yes  NoIncontinence Yes  NoAgitation/Irritability

 Yes  NoSlow starting or stopping urine Yes  NoInsomnia

Other: ______ Yes  NoAnxiety

 Yes  NoFrequent crying spells

Genital/Sex Organs Other: ______

 Yes  NoPenile Discharge

 Yes  NoTesticular lump/painNeurologic

 Yes  NoBreast Pain/discharge/Lump Yes  NoFrequent headaches

 Yes  NoPainful intercourse Yes  NoSeizures

 Yes  NoLack of sexual desire Yes  NoSyncope (passing out)

 Yes  NoProblems with performance Yes  NoLimb weakness

Other: ______ Yes  NoLimb numbness

 Yes  NoDizziness

Musculoskeletal Yes  NoDifficulty Swallowing

 Yes  NoJoint pains/stiffness Yes  NoBalance issues

 Yes  Nojoint swelling Yes  NoTremors

 Yes  NoMuscle weakness Yes  NoRigidity

 Yes  NoBack pain Yes  NoHistory of Falls

 Yes  NoMuscle spasms/crampsOther: ______

 Yes  Nofalling

Other: ______

Calhoun Liberty Hospital Primary Care ClinicHealth History Intake Form4