<p> Stone Meadow Health and Wellness Health History Form</p><p>Today’s Date:______</p><p>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</p><p>Current Health Problems: Why are you being seen today? ______</p><p>General Health: On the following line, place an X where you would rate your current overall health. ______Poor Health Maximal Health</p><p>Current Medications: Please list all medications you take on a regular basis, including over-the counter medications, vitamins, and herbs.</p><p>Name of Medication Dose How often or when do you take it?</p><p>Drug Allergies Are you allergic to any medications? Yes____ No____ If yes, please list the medication and what happens when you take them.</p><p>Medication Reaction</p><p>Have you ever received a blood transfusion? No_____Yes____ Dates______Past Medical History</p><p>1. Please list any nondental surgeries, hospitalizations, or childhood illnesses you have had and the approximate dates you had them.</p><p>Surgery, Hospitalizations, or childhood illnesses Date</p><p>2. Chronic Medical Conditions (please circle)</p><p>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:______</p><p>Family Medical History</p><p>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.)</p><p>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</p><p>Vaccinations Vaccine Date Vaccine Date Tetanus Hepatitis B Influenza (flu) Rabies Pneumonia Polio Zostavax MMR Varicella (chicken pox) Other:______HPV (gardasil) Other:______</p><p>Women: # pregnancies_____, miscarriages_____, live births______. Date of last menstrual period______Birth control method______. Problems:______</p><p>Prefer to have sex with (circle): men, women, both</p><p>Seatbelt use (circle): 100% 75% 50% 25% 0% Sun exposure (circle): Frequently Occasionally Rarely Sunscreen: Y / N</p><p>Exercise: Yes___ No___ Times per week: ____ Minutes:______Type:______</p><p>Caffeinated beverages per day: _____ Drinks</p><p>Alcoholic beverages per week: ______Drinks (beer, wine, other)</p><p>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</p><p>Describe your smoking/ chewing tobacco use: Never:______Current:______(packs, cigars, pipes, cans/ day) for ______years Quit:______(date), ______(packs, cigars, pipes, cans/ day) for _____ years</p><p>Drug use (please circle): none, marijuana, cocaine, crack, heroin, meth, other:______</p><p>HIV risk factors (please circle): intravenous drug use, multiple sex partners, no condom use, work-related, none</p><p>Are you in an abusive (physical, verbal, or emotional) relationship? Yes____ No ____</p>