All questions in this questionnaire are strictly confidential and will become part of your medical record.

__________________________________________________________________________________________________________________________________________________________________________________________________________

Patient Last Name:

First Name:

MI:

Today's Date:

Reason for Visit:

What kind of smartphone do you have?

Previous or Referring Doctor:

Patient Gender:

DOB:

Phone Number

Last 4 of Your Social Security Number

PERSONAL HEALTH HISTORY (PAST MEDICAL HISTORY)

Conditions you have had in the past (check all that apply):

Surgeries

Year

Reason

Hospital

Hospitalizations

Year

Reason

Hospital

Have you ever had a blood transfusion?

Do you know your blood type?

Blood Type:

List your prescribed medications and over-the-counter drugs, such as vitamins and inhalers

Do you have prescribed medications?

If yes, please list prescribed medications:

Drug Name

Strength

Frequency Taken

Allergies to medications

Do you have any allergies to medications?

If yes, please list medications you are allergic to:

Drug Name

Reaction You Had

HEALTH HABITS AND PERSONAL SAFETY (SOCIAL HISTORY)

(All Questions Contained in this Questionnaire are Optional and will be Kept Strictly Confidential)

Drugs

Do you currently use recreational or street drugs?

Have you ever given yourself street drugs with a needle?

Personal Safety

Do you live alone?

Do you have frequent falls?

Do you have vision or hearing loss?

Physical and/or mental abuse have become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your doctor or his staff?

OCCUPATION

Current Occupation

If Retired, Please State Past Occupation

FAMILY HEALTH HISTORY

Father

Age

Age at Death

Significant Health Problems

Mother

Age

Age at Death

Significant Health Problems

Sibling 1

Age

Age at Death

Significant Health Problems

MENTAL HEALTH QUESTIONNAIRE

Is stress a major problem for you?

Do you cry frequently?

Do you feel depressed?

Have you ever seriously thought about hurting yourself?

Do you panic when stressed?

Do you have trouble sleeping?

Do you have problems with eating or your appetite?

Have you ever been to a counselor?

DO YOU HAVE ANY OF THE FOLLOWING

Food Insecurity

Housing Instability

Transportation Problems

Home Security Concerns

SCREENINGS (please indicate most recent date)

Last Colonoscopy:

Normal

Abnormal

Cholesterol Screening:

Normal

Abnormal

Test for Blood in Stools:

Normal

Abnormal

Electrocardiogram:

Normal

Abnormal

REVIEW of SYSTEMS (check all that apply to you)

Contstitutional

Wt. Loss or Gain

Fever

Fatigue

Chills

Eyes

ENT/Mouth

Allergy/Immunology

Rashes/Hives/Welts

Itchiness

Allergic Asthma/Bronchitis

Neurology

Psychiatry

Depression

Mood Swings

Memory Problems

Anxiety

Endocrinology

Skin

Skin Rashes

Bruising

Changes in Skin Lesions

Wounds

Ulcers

Genitourinary

Burning Urination

Excessive Urination

Incontinence of Urine

Blood in Urine

Frequent Bladder/Kidney Infections

History of Sexually Transmitted Disease

Gastrointestinal

Hematology/Lymphatics

Bruising

Nosebleeds

Lack of Energy

Respiratory

Frequent Lung Infections

Shortness of Breath

Chest Tightness

Wheezing

Sleeping Problems

Persistent Cough

Asthma

Cardiovascular

History of Rheumatic Fever

Palpitations

Chest Pain

Swelling Hands

Swelling Feet

Irregular Heartbeat

High or Low Blood Pressure

Musculoskeletal

Difficulty Walking

Joint Stiffness

Muscle Pains

Back Pain

Pain During Walking

WOMEN ONLY

Age at Menstruation:

Date of Last PAP Smear:

Normal

Abnormal

Number of Pregnancies:

Number of Live Births:

Date of or Age at Last Menstruation:

Last Mammogram:

Normal

Abnormal

Bone Density Screening:

Normal

Abnormal

Experienced any recent breast tenderness, lumps, or nipple discharge?

Yes

Date of Last Rectal Exam:

Normal

Abnormal

MEN ONLY