WellSpring Medical Group

Transcription

1 Health Questionnaire Date Patient Name Referred by Date of Birth Age Occupation What is the main reason for which you are seeing the Doctor? Medications/ Vitamins/ Supplements Please list all drugs, vitamins and dietary supplements you are current taking. If possible, list starting date and dosage. Medications Dose Nutrition Supplements Allergies Yes No Effect Effect Penicillin [ ] [ ] Other: Septra [ ] [ ] Other: Iodine [ ] [ ] Other: Shell Food [ ] [ ] Other: Hospitalizations, Operations (including plastic surgery), and/or Serious Injuries Year Hospitalization-Operation-Injury Hospital & Location Immunization History [ ] Chickenpox Date: [ ] Meningococcus Date: [ ] Flu Shot Date: [ ] MMR (Measles,Mumps,Rubella) Date: [ ] Gardisil/HPV Date: [ ] Pneumonia Date: [ ] Hepatitis A Date: [ ] Tdap (Tetanus and pertussis) Date: [ ] Hepatitis B Date: [ ] Tetanus Date: [ ] Zostavax (shingles) Date: [ ] Last TB skin test Date: TB Test Result = Neg [ ] Pos [ ] Page 1 of 5

2 Sexual Orientation [ ] Strictly heterosexual [ ] Bisexual [ ] Not Sexually Active [ ] Strictly homosexual [ ] Transgender [ ] Unknown Mental/ Emotional Ailments (Circle the appropriate letter C = CURRENTLY P = PAST N = NEVER) Depression C P N Mood Swings C P N Indecision C P N Anxiety C P N Helpless Feelings C P N Heartache C P N C = CURRENTLY P = PAST N = NEVER Psychological History Presently In the Past Psychotherapy [ ] [ ] Specify Antidepressants [ ] [ ] Specify Other psychiatric medications [ ] [ ] Specify Have you ever been admitted to a hospital for a psychological evaluation? Yes [ ] No [ ] If yes, please specify when and the duration of stay for each episode: Smoking (cigarettes) Past Use Present Use packs/day years total packs/day years total Alcohol [ ] None [ ] I have a drink about 3-5 times per week [ ] I no longer drink; [ ] I seldom drink [ ] I have a drink usually every day I m in recovery Please state what type(s): Recreational Drug Use Please discuss with your provider. Exercise Check one of the following statements: [ ] I make no effort to obtain regular exercise [ ] I live an active life and get my workouts from daily living activities [ ] I make a modest effort to obtain regular exercise (1-3 times weekly) [ ] I obtain regular exercise 3-5 times per week (at least 30 min/session) [ ] I obtain regular exercise > 5 times per week (at least 30 min/session) Favorite Exercise Activities Duration Times per Week Page 2 of 5

3 Illness & Medical Problems (Circle the appropriate letter C = CURRENTLY P = PAST N = NEVER) Anemia C P N Diabetes C P N Mononucleosis C P N Arthritis C P N Diverticulosis C P N Other Lung problems C P N Asthma C P N Dizzy spells C P N Paralysis C P N Bleed easily C P N Ear trouble C P N Pneumonia C P N Bleeding Disorder C P N Emphysema C P N Repeated nose bleeds C P N Bronchitis C P N Gall bladder trouble C P N Rheumatic Fever C P N Bruise easily C P N Glaucoma C P N Scarlet fever C P N Cancer C P N Heart attack C P N Sinus trouble C P N Year & Type of Cancer: Heart condition C P N Stomach/Duodenal ulcer C P N Heart murmur C P N Stroke C P N Chronic nose obstruction C P N Hepatitis C P N Swelling in neck C P N Convulsion/Seizures C P N High blood pressure C P N Trouble with anesthesia C P N Deafness or decreased hearing C P N Low blood pressure C P N Tuberculosis C P N Physical Ailments (Circle the appropriate letter C = CURRENTLY P = PAST N = NEVER) Back pain C P N Gas (dyspepsia) C P N Shortness of breath C P N Bloody stools C P N Headaches C P N Shoulder pain C P N Chest pains C P N Heartburn C P N Tiredness C P N Constipation C P N Indigestion C P N Weight loss C P N Diarrhea C P N Neck pain C P N Weight gain C P N Dizziness C P N Poor appetite C P N Wheezing C P N Women Only (Circle the appropriate letter C = CURRENTLY P = PAST N = NEVER) Bleeding between periods C P N Tender breasts C P N Date of last period: Breast lump or nipple C P N Vaginal itching, burning, discharge C P N discharge Extreme menstrual pain C P N The Number of: Fibrocystic disease C P N Age of first menstrual period: Pregnancies: Heavy periods C P N Age of menopause: Births: Hot flashes C P N Last pap smear date: Abortions: Lumps or recent change in size C P N Abnormal? Yes No Miscarriages: Menstrual problems C P N Last mammogram date: Cesarean sections Yes No Painful intercourse C P N Abnormal? Yes No if yes, then number: Do you use condoms? Yes No Other birth control method used: Family History Asthma Yes No Diabetes Yes No Renal Disorder Yes No Bleeding Tendency Yes No Glaucoma Yes No Rheumatoid arthritis Yes No Blood Disorders Yes No Heart disease Yes No Tuberculosis Yes No Cancer Yes No High blood pressure Yes No Ulcer disease Yes No Llist the ages and Health Problems of your family. If a family member has died, indicate at what age they died and their cause of death. Father Mother Brothers & Sisters Children Page 3 of 5

4 Occupation: Hours worked per week: Vacation time per year: Job Satisfaction: [ ] Great [ ] OK [ ] Lousy Where were you born? Where did you grow up? How many years in school did you have? Who lives in your household? Marital Status: [] Married [] Single [] Divorced [] Separated [] Widowed [] Domestic Partner No. of children: List their sex and ages: Friends: [ ] I have many warm and close relationships [ ] I have many friends [ ] I have a few close friends [ ] I don t have any real close friends Do you have a significant other? [ ]Yes [ ]No How long: Do you have close contact with your family? [ ]Yes [ ]No Are you seeing a therapist or have support group? [ ]Yes [ ]No Have you traveled within the past 3 years (outside the USA)? [ ]Yes [ ]No Do you have a primary support person? [ ]Yes [ ]No Name: Phone: How many times have you moved in the past two years? Any recent stressful events: [ ]Yes [ ]No If yes, explain briefly: General Stress Level: [ ]Low [ ]Medium [ ]High Diet: [ ]Regular [ ]Diabetic [ ]Low fat [ ]Vegetarian [ ] Vegan [ ]Gluten Free [ ]Other: Seat Belts Used Routinely: [ ]Yes [ ]No Smoke Alarm at home: [ ]Yes [ ]No Sunscreen Used Routinely: [ ]Yes [ ]No Are guns present in your home? [ ]Yes [ ]No Is your partner, spouse, or anyone in your family abusing or harming you? [ ]Yes [ ]No Do you feel safe at home? [ ]Yes [ ]No If no, please explain: Please complete the following page ONLY if you are HIV+ (positive) Page 4 of 5

5 Complete this page ONLY if you are HIV + (positive) Year of seroconversion or first positive HIV Test: Lowest CD4: Date: Highest CD4: Date: Recent Laboratory Values List, to the best of your ability, your three last blood tests: Date Viral Load (PCR or bdna) Helper T-Cell Number (CD$) List any past antiretroviral(s) Indicate if they were stopped because of side effects (S) or viral breakthrough (F) Antiretroviral Reason for stopping Antiretroviral Reason for stopping HIV Speciality Tests [ ] Genotype Are results available? [ ]Yes [ ] No [ ] Phenotype Are results available? [ ]Yes [ ] No [ ] Trophile Results?: R5 DT or CXR4 [ ] HLA B5701 Results?: POS or NEG Are you presently or have you in the past, participated in any HIV associated research clinical trials? [ ] Yes [ ] No If Yes, please list the trial(s) and any pertinent information: Past Medical History - Have you ever been diagnosed with any of the following illnesses? [ ] Anal Dysplasia [ ] High cholesterol [ ] Bacterial Pneumonia [ ] Herpes Zoster (Shingles) [ ] Cervical Dysplasia [ ] Intestinal infection [ ] CMV Retinitis/Colitis [ ] Kaposi s Sarcoma [ ] Cryptococcal Meningitis [ ] Lymphoma [ ] Exposure to Tuberculosis [ ] MAI [ ] Genital or Rectal Herpes [ ] Oral Candidiasis (thrush) [ ] Genital warts [ ] Oral Herpes Infection [ ] Gonorrhea [ ] Pneumocystis Pneumonia [ ] Hairy Leukoplakia [ ] Syphilis [ ] Hepatitis A [ ] Tuberculosis [ ] Hepatitis B [ ] Other: [ ] Hepatitis C [ ] Other: Do you practice safe sex? [ ] Yes [ ] No [ ] Sometimes If Yes, with whom? [ ] All Partners [ ] Unknown Partners [ ] Known Partners Page 5 of 5