MGH Beacon Hill Primary Care
Interim History Form
For Office Use Only
Date___________
Reviewed By
Name_______________________________________________ Date of birth ___________
Medical History
What are your health concerns for this checkup? ___________________________________________________
_____________________________________________________________________________________________
Have you had any major health or personal problems since your last checkup? Yes
No
If yes, please explain ______________________________________________________________________
Have you made any important changes in your life or health habits since your last checkup? Yes
No
If yes, please explain ______________________________________________________________________
Does your health make it hard to maintain your daily activities? Yes
No
If yes, please explain ______________________________________________________________________
Review of Systems
Please indicate if you are having concerns about any of the following:
General
Weight loss
Fever
Bleeding
Lumps
Weakness
Fatigue
Pain
Growths
Trouble sleeping
Eyes
Vision problem
Redness
Excess tears
Ears
Hearing problem
<Continued>
Popping
Stuffiness
Mouth
Difficulty chewing
Tooth problem
Heart and Lungs
Cough
Abnormal heart beats
Snoring
Wheezing
Gastrointestinal
Heartburn
Difficulty swallowing
Black stool
Blood in stool
Diarrhea
Constipation
Excess gas
Genitourinary
Difficulty urinating
Frequent urination
Loss of urine
Sexual problem
Musculoskeletal
Stiff joint
Swollen joint
Back trouble
Neck trouble
Skin
Rash
Unusual mole
Acne
Itch
Neurologic
Numbness
Shakiness
Difficulty walking
Emotional
Sadness
Anxiety
Unusual thoughts
Other emotional problems
__________________________
Endocrine
Excessive hunger
Excessive thirst
Heat sensitivity
Cold sensitivity
Hematologic
Infection
Black and blue marks
Other problems ____________________________________________________________________________
Additional Questions
Have you ever used recreational or illegal drugs? Yes
No
Have you ever been in a relationship with a person who hurt or threatened you? Yes
No
Have you ever been in a relationship with a person whom you have hurt or threatened? Yes
Are you currently sexually active? Yes
<Continued>
No
If yes, with: Men
Women
No
Both
Do you have any beliefs, values or ideas that your doctor should know about? Yes
No
If yes, please explain ______________________________________________________________________
Is there anything else you would like to discuss today? Yes
No
If yes, please explain ______________________________________________________________________