Name__________________________________________ DOB______________ MEDICAL HISTORY (Please check the box if you CURRENTLY HAVE OR HAVE HAD a history of the following): ___ Environmental Allergies/Hay fever ___ Glaucoma ___ Irritable Bowel Syndrome ___ Inflammatory Bowel Disease (Crohn’s or Colitis) ___ Kidney Stones ___ Kidney Disease ___ Osteoporosis ___ Arthritis: Type-­‐ Osteo or Rheumatoid ___ Gout ___ Anemia ___ Bleeding problems ___ Tuberculosis ___ Vision loss or Blindness ___ Hearing Loss ___ Diabetes: Type 1 or Type 2 ___ Thyroid Disorder: Hyper or Hypo ___ Asthma ___ COPD/Emphysema ___ Sleep Apnea ___ High Blood Pressure (Hypertension) ___ High Cholesterol (Hyperlipidemia) ___ Heart Murmur ___ Arrhythmia (Atrial Fibrillation, tachycardia) ___ Heart Disease (Heart Attack, Stent, Failure) ___ Stroke ___ Blood Clot in leg or lung ___ Liver Disease ___ Acid reflux or Ulcers ___ Skin Disease ___ Migraines or other headaches ___ Neuropathy ___ Seizure Disorder ___ Anxiety ___ Depression ___ Bipolar ___ ADHD Gynecologic Problem (Types) __________________________________________________________________________ Male Health Problems (Types) _________________________________________________________________________ Cancer: Location(s)__________________________________________________________________________________ Major Injuries: _____________________________________________________________________________________ Other (Please list): __________________________________________________________________________________ __________________________________________________________________________________________________ Surgeries (Please check if you have had any of the following and write location if indicated):
Cataract removal ( Left Right Both) Ear Tubes Nose/Sinus Surgery Tonsillectomy / Adenoidectomy Carotid Artery Surgery ( Left Right Both) Heart Catheterization / Stent Open Heart Surgery (Bypass) Heart Valve Replacement Gallbladder Removal Appendectomy Gastric Bypass or Lap Band Hernia Repair Prostate Surgery Vasectomy Tubal Ligation Hysterectomy Ovaries removed C-­‐Section Mastectomy ( Left Right Both) Broken Bone repair:_______ Joint Replacement:_________ Joint Scope:_______________ Spine Surgery Skull/Brain Surgery Other Surgery: ______________________________________________________________________________________ Other Hospitalizations: (Excluding Emergency visits) __________________________________________________________________________________________________ Name__________________________________________ DOB______________ Health Maintenance: Last physical:___________________________________________________________________________________ Last Blood tests (Date and what test and results if known-­‐ or attach a copy of your last results): ______________________________________________________________________________________________ Colonoscopy (Date and results if known):_____________________________________________________________ Mammogram (Date and results if known):____________________________________________________________ Bone Density (Date and results if known): ____________________________________________________________ Immunization Dates: Tetanus_______ Flu________ Hepatitis B_______ Hepatitis A_______ Pneumonia________ Chickenpox _______ Shingles_______ HPV_______ Other_____________________________________________ FAMILY HISTORY (please check): High Blood Pressure Mother Father Sibling Child Grandmother Grandfather High Cholesterol Mother Father Sibling Child Grandmother Grandfather Heart Disease or Heart Failure Mother Father Sibling Child Grandmother Grandfather Stroke Mother Father Sibling Child Grandmother Grandfather Blood clot Mother Father Sibling Child Grandmother Grandfather Asthma Mother Father Sibling Child Grandmother Grandfather Autoimmune disease [type]__________________ Mother Father Sibling Child Grandmother Grandfather Diabetes ( Type 1 or Type 2) Mother Father Sibling Child Grandmother Grandfather Thyroid Disorder Mother Father Sibling Child Grandmother Grandfather Cancer [type]______________________________ Mother Father Sibling Child Grandmother Grandfather Seizure Disorder Mother Father Sibling Child Grandmother Grandfather Migraines Mother Father Sibling Child Grandmother Grandfather Depression Anxiety Bipolar Disorder (Check) Mother Father Sibling Child Grandmother Grandfather Arthritis Mother Father Sibling Child Grandmother Grandfather Osteoporosis Mother Father Sibling Child Grandmother Grandfather Other:________________________________________________________________________________________________
_____________________________________________________________________________________________________ LIFESTYLE AND OTHER HISTORY: Who do you live with: ________________________________________________________________________________ Occupation/Schooling: _______________________________________________________________________________ Describe your eating habits: ___________________________________________________________________________ Describe your exercise routine: ________________________________________________________________________ Hobbies:___________________________________________________________________________________________ Hours of TV/Computer/Video Games per day: ____________________________________________________________ Tobacco use (Type, How much per day and how many years):________________________________________________ Alcohol use (Type, How much, how often and how many years): ______________________________________________ Recreational drug use (Type, How much, how often and how many years):______________________________________ High Risk Behaviors: _________________________________________________________________________________ Behavioral Health Care and Therapist: ___________________________________________________________________ Other information you would like to share: _______________________________________________________________ __________________________________________________________________________________________________