Health History Intake Form Your physician today: □ Jeffrey Absalon, MD □ Sanaz Askari, DO □ Mark Backus, MD

Today’s Date:______Patient Name:______Date of Birth:______Age:______

Previous Primary Care Physician (if any):______Phone:______Address:______Other Physicians involved in your care:______Reason for visit today: ______

Allergies (Medication/Food, indicate reaction): □ None ______

Medication List: (Please list name/dose/frequency if known) ______

Family History: (please indicate deceased or alive, medical issues and age) Father:______Mother:______Siblings:______Grandparents:______

Cascade Internal Medicine Specialists Health History Intake Form 1

Habits: Alcohol: □ None □ Yes: How many drinks/day ______frequency/week ______What kind______Tobacco: □ None □ Yes: Chew or smoke?______How many/day ______since______Caffeine: □ None □ Yes: What kind______How many/day ______Other Recreational Drugs: □ None □ Yes: What kind______How many/day ______Do you drive? □ Yes □ No Do you always wear a seatbelt? □ Yes □ No Do you exercise? □ Yes □ No If yes, how much?______

Social History: Work: □ Employed □ Unemployed □ Retired □ Disabled Current Occupation ______Former Occupation ______Marital Status: □ Married □ Single □ Divorced □ Domestic Partner Sexual preference: □ Men □ Women □ Both Children (age):______Hobbies:______Sports:______Pets:______Other:______

Past Surgical History (indicate date if known)

□ None □ Bariatric surgery______□ Cataracts______□ Hysterectomy______□ LASIK______□ Endoscopy______□ Tonsillectomy______□ Colonoscopy______□ Thyroidectomy______□ Hernia______□ Adenoidectomy______□ Spinal Surgery______□ Coronary Bypass______□ Tubal Ligation______□ Cardiac Stents______□ Bladder surgery______□ Pacemaker______□ Prostate surgery/resection______□ Heart Valve______□ C-Section______□ Gall Bladder______□ Orthopedic/joints______□ Appendectomy______□ Bowel/Stomach Resection______□ Other______□ Hemorrhoidectomy______

______

Cascade Internal Medicine Specialists Health History Intake Form 2

Past Medical History: Head Aches □ Yes □ No Date: ______Stroke □ Yes □ No ______Seizures □ Yes □ No ______Pneumonia □ Yes □ No ______Diabetes (Type 1 or Type 2) □ Yes □ No ______Thyroid Disease (Low or High) □ Yes □ No ______Glaucoma □ Yes □ No ______Macular Degeneration □ Yes □ No ______Hearing Loss □ Yes □ No ______High Blood Pressure □ Yes □ No ______Blood Clots □ Yes □ No ______□ Pulm Emboli (lung clots) □ Yes □ No ______□ DVT (leg clots) □ Yes □ No ______Heart Burn, Reflux □ Yes □ No ______Stomach Ulcers □ Yes □ No ______Heart Disease □ Yes □ No ______□ Coronary Disease □ Yes □ No ______□ MI/heart attacks □ Yes □ No ______□ Congestive Heart Failure □ Yes □ No ______□ Atrial Fibrillation □ Yes □ No ______□ Angina □ Yes □ No ______□ Valve Disorder □ Yes □ No ______High Cholesterol □ Yes □ No ______Gastrointestinal Bleeding □ Yes □ No ______Hepatitis (A, B, C) □ Yes □ No ______HIV / AIDS □ Yes □ No ______Chronic Wounds □ Yes □ No ______Cancer (type) □ Yes □ No ______Urinary Tract Infections □ Yes □ No ______Incontinence □ Yes □ No ______Kidney Stones □ Yes □ No ______COPD (Emphysema, Bronchitis) □ Yes □ No ______Asthma □ Yes □ No ______Depression □ Yes □ No ______Bipolar Disorder □ Yes □ No ______Anxiety □ Yes □ No ______Fibromyalgia □ Yes □ No ______Chronic Fatigue Syndrome □ Yes □ No ______Arthritis □ Yes □ No ______Gout □ Yes □ No ______Osteoporosis □ Yes □ No ______Prostate Disease □ Yes □ No ______Breast Disease □ Yes □ No ______Erectile Dysfunction □ Yes □ No ______Other______

Cascade Internal Medicine Specialists Health History Intake Form 3

Review of Systems (√ Yes or No for symptoms in past 6 months, circle for symptoms TODAY)

Constitutional/Endocrine Last pap smear:______□ Yes □ No Fever Results:______□ Yes □ No Chills Total Pregnancies:______□ Yes □ No Weakness/Fatigue Total live births:______□ Yes □ No Weight Loss Total miscarriages:______□ Yes □ No Weight Gain Total abortions:______□ Yes □ No Insomnia Total C-sections:______

□ Yes □ No Snoring Cardiac □ Yes □ No Excessive thirst □ Yes □ No Chest pain □ Yes □ No Excessive urination □ Yes □ No Palpitation □ Yes □ No Cold or Heat intolerance □ Yes □ No Irregular heartbeat Other:______□ Yes □ No Exercise intolerance

HEENT □ Yes □ No Leg swelling □ Yes □ No Sore Throat Other:______

□ Yes □ No Stiff neck Respiratory □ Yes □ No Change in your voice □ Yes □ No Persistent Cough □ Yes □ No Sinus Drainage □ Yes □ No Coughing up blood □ Yes □ No Sinus Head Ache □ Yes □ No Shortness of breath □ Yes □ No Nose Bleeds □ Yes □ No Wheezing □ Yes □ No Ear ache/drainage □ Yes □ No Can’t breathe laying flat □ Yes □ No Hearing Loss Other:______□ Yes □ No Ringing in your ears □ Yes □ No Blurred Vision/Loss Skin □ Yes □ No Wear glasses or contacts □ Yes □ No Rashes/Hives □ Yes □ No Itchy/watery eyes □ Yes □ No Skin discoloration □ Yes □ No Dental problems □ Yes □ No Lesions/moles/warts Other:______□ Yes □ No Ulcers □ Yes □ No Itching Gastrointestinal □ Yes □ No Nail Problems □ Yes □ No Nausea /Vomiting □ Yes □ No Unusual Hair loss □ Yes □ No Difficulty swallowing □ Yes □ No Easy bruising □ Yes □ No Hemorrhoids Other:______□ Yes □ No Diarrhea □ Yes □ No Constipation Psych □ Yes □ No Bloody or Black Stools □ Yes □ No Depressed mood □ Yes □ No Abdominal pain □ Yes □ No Suicidal thoughts/plans □ Yes □ No Heart burn/indigestion □ Yes □ No Agitation/irritability □ Yes □ No Frequent use of Laxatives □ Yes □ No Insomnia Other:______□ Yes □ No Anxiety □ Yes □ No Frequent crying spells Urinary Other:______□ Yes □ No Pain or burning with urination □ Yes □ No Urinary frequency (Night or Day) Musculoskeletal □ Yes □ No Blood in urine / Dark urine □ Yes □ No Joint pains or stiffness □ Yes □ No Incontinence □ Yes □ No Joint swelling □ Yes □ No Slow starting or stopping urine □ Yes □ No Muscle weakness Other:______□ Yes □ No Back pain

□ Yes □ No Muscle spasms/cramps Genital/Sex Organs □ Yes □ No Falling □ Yes □ No Penile discharge Other:______□ Yes □ No Testicular lump/pain □ Yes □ No Breast Pain/discharge/lump Neurologic □ Yes □ No Painful intercourse □ Yes □ No Frequent Headache □ Yes □ No Lack of sexual desire □ Yes □ No Seizures □ Yes □ No Problems with performance □ Yes □ No Syncope (passing out) Other:______□ Yes □ No Limb weakness □ Yes □ No Limb numbness FEMALE Reproductive □ Yes □ No Dizziness □ Yes □ No Hot Flashes □ Yes □ No Swallowing difficulty □ Yes □ No Bleeding after menopause □ Yes □ No Balance issues □ Yes □ No Excessive menstrual bleeding □ Yes □ No Tremors □ Yes □ No Unusual vaginal discharge □ Yes □ No Rigidity Age at onset of menstruation______Other:______1st day of last menstruation______□ Yes □ No Menstrual pain/cramps ______□ Yes □ No Spotting between periods

Cascade Internal Medicine Specialists Health History Intake Form 4