1PA

*1PA* BRIEF OUTPATIENT HEALTH HISTORY

PLEASE CIRCLE CORRECT RESPONSE BELOW: Glasses / Contacts Dentures: Uppers / Lowers Partial: Uppers / Lowers Hearing Aid: Left / Right Loose Teeth # ______

Current Medications Dosage Frequency Last Dose Current Medications Dosage Frequency Last Dose 1. 7. 2. 8. 3. 9. 4. 10. 5. 11. 6. 12. PATIENT HEALTH HISTORY – check all that apply History of History of History of  Asthma  Stroke /T IAs When:______ Seizures / Epilepsy  Bronchitis or Chronic Cough  Pacemaker When:______ Anemia  Emphysema  Heart Murmur  Blood Transfusion  Shortness of Breath  Chest Pain / Angina  Disease/Ulcer  Pneumonia  Congestive Heart Failure  Hiatal  Tuberculosis When: ______ Ankles swelling  / disease  Never Smoked  Fluid in lungs  HIV  Currently Smokes # of packs per day ______ Palpitations irregular /  Arthritis  Ex-smoker Month & Year quit: ______fast heartbeat  Disabilities What:______ Live with a smoker  Rheumatic fever  Kidney Disease  Caffeine use  High/Low Blood Pressure  Thyroid  Alcohol use  Previous Heart Cath  / Last Accu Result ______ History of MRSA  Angioplasty / stent When:  Hypoglycemia Date ______Time ______ Peripheral  History of sleep apnea  Dizziness/Motion Sick  Blood Clot in legs When:______ CPAP Settings:  Prostate/bladder problems  Heart Attack When:______ Oxygen at night  Cancer What______When ______ Last BM ______ Last menstrual period  Pneumococcal vaccine When ______ Influenza vaccine When ______SURGICAL HISTORY – check all that apply  Heart Surgery  Tonsillectomy When:______ Bypass When:______ Gallbladder When:______ Valve When:______ Hysterectomy When:______ Blood Vessels – neck (carotid) When:______ Appendectomy When:______ Blood Vessels – legs When:______OTHER – please list: When:______ Anesthesia Reaction: What happened:______When:______ALLERGIES – please list Allergy to iodine, shellfish, seafood  Yes  No Allergies: Reactions: Allergies: Reactions: Allergies: Reactions: Allergies: Reactions: Allergies: Reactions:

PATIENT NAME: DATE:

EMERGENCY CONTACT NAME: PHONE NUMBER:

HOSPITAL USE ONLY

Last ate at:______

Date:______Time:______Ht:______Wt:______

T:______P:______R:______BP:______SAO2:______%

Signature/Title:______Initials:______

KHH 156, 10/08/2015