Stone Meadow Health and Wellness Health History Form

Today’s Date:______

Name: ______Date of Birth:______Occupation:______Partner Status: (circle): Married, Widowed, Divorced, Single, Significant Other, Boyfriend, Girlfriend, Life Partner Who do you live with? ______What Pharmacy do you use?______Do you have an advanced directive (living will or durable power of attorney for health care)? Yes No

Current Health Problems: Why are you being seen today? ______

General Health: On the following line, place an X where you would rate your current overall health. ______Poor Health Maximal Health

Current Medications: Please list all medications you take on a regular basis, including over-the counter medications, vitamins, and herbs.

Name of Medication Dose How often or when do you take it?

Drug Allergies Are you allergic to any medications? Yes____ No____ If yes, please list the medication and what happens when you take them.

Medication Reaction

Have you ever received a blood transfusion? No_____Yes____ Dates______Past Medical History

1. Please list any nondental surgeries, hospitalizations, or childhood illnesses you have had and the approximate dates you had them.

Surgery, Hospitalizations, or childhood illnesses Date

2. Chronic Medical Conditions (please circle)

Asthma Kidney problems Peripheral vascular disease Heart arrhythmia Diabetes (type 1/ 2) Stomach ulcers Anemia Bowel problems (type______) Rheumatoid arthritis Anxiety Cholesterol problems Seizure disorder Autoimmune disorder Thyroid problems Tuberculosis Allergies Depression Cancer (type______) Barrett’s esophagitis Liver problems Recurrent urinary tract infections COPD Mental health problems Enlarged prostate Heart problems Osteoporosis Other:______Eating disorder Osteoarthritis Other:______

Family Medical History

Do you have any history of the following conditions in your blood relatives, including your grandparents? (For mother’s parents use initials MGM and MGF. For father’s parents use PGM and PGF.)

Disease and Who had the disease? Anesthesia complications Seizures Mental health problems (type______) Gout High blood pressure Alcoholism Bleeding disease Stroke Anxiety Cancer (type______) Depression Allergies/ Asthma Diabetes Thyroid problems Heart problems Headaches High cholesterol Endometriosis Kidney disease Blood clots Lung/ respiratory disease Alzheimer’s disease Osteoporosis Other:______Health Maintenance Please give the most recent date of the following tests/ exams. Test/ Exam Date Test/ Exam Date Complete Physical exam Dental exam/ cleaning Blood Screening (health fair labs) Men: Prostate Exam Urine screening PSA blood test Chest X-ray Women: Mammogram Colonoscopy Pap smear Eye exam Breast exam Bone Density Pelvic exam

Vaccinations Vaccine Date Vaccine Date Tetanus Hepatitis B Influenza (flu) Rabies Pneumonia Polio Zostavax MMR Varicella (chicken pox) Other:______HPV (gardasil) Other:______

Women: # pregnancies_____, miscarriages_____, live births______. Date of last menstrual period______Birth control method______. Problems:______

Prefer to have sex with (circle): men, women, both

Seatbelt use (circle): 100% 75% 50% 25% 0% Sun exposure (circle): Frequently Occasionally Rarely Sunscreen: Y / N

Exercise: Yes___ No___ Times per week: ____ Minutes:______Type:______

Caffeinated beverages per day: _____ Drinks

Alcoholic beverages per week: ______Drinks (beer, wine, other)

How would you describe your diet? (please circle) Low calorie Low fat/ cholesterol 1400 calorie ADA Vegetarian Regular Low sodium 1200 calorie ADA 1600 calorie ADA Vegan

Describe your smoking/ chewing tobacco use: Never:______Current:______(packs, cigars, pipes, cans/ day) for ______years Quit:______(date), ______(packs, cigars, pipes, cans/ day) for _____ years

Drug use (please circle): none, marijuana, cocaine, crack, heroin, meth, other:______

HIV risk factors (please circle): intravenous drug use, multiple sex partners, no condom use, work-related, none

Are you in an abusive (physical, verbal, or emotional) relationship? Yes____ No ____