MEDICAL HISTORY FORM Patient Name: _____________________ DOB: ______/______/_______ Signature: ________________________ Date: _____/______/________ Present Health Concerns: __________________________________________________________________________________________ Please list all prescription and non-prescription medicines, MEDICATIONS: ALLERGIES: List all reactions to medicines, foods and other agents. vitamins, home remedies, birth control pills, herbs etc. Medication Name Dose Frequency Allergy Reaction or Side Affect ** If you are on 3 or more medications – please bring them with you to each appointment. ** PERSONAL MEDICAL HISTORY: Please indicate whether you have had any of the following medical problems. Congenital Heart Disease: Cancer (Malignancy) Hepatitis A, B, or C (specifiy)_______ please specify:_________________ please specify:________________ Date of Last Colonoscopy: ____________ Myocardial Infarction (Heart Attack) Stroke Date of last Tetanus Shot: ____________ Hypertension (High Blood Pressure) Coagulation (Bleeding/Clotting) Date of last HIV Test: ________________ Diabetes Depression/Suicide Attempt Date of Blood Transfusion: ___________ High Cholesterol Alcoholism Other:____________________________ SURGICAL HISTORY: Please list all prior surgeries and dates. Surgery Date IMMUNIZATIONS: Please list your most recent immunizations, not including those administered at Lowell General Hospital. Please include your best estimate of the month and year of each immunization. Hepatitis A: _________ Measles: ___________ Mumps: ____________ Rubella: ____________ MMR: ______________ Hepatitis B: _________ Pneumovax: ________ Tdap: ______________ Varicella: ___________ Other: _____________ WOMEN’S HEALTHY GYNECOLOGIC/OBSTETRIC HISTORY: (For Women Only) # of Pregnancies: _____ # of Deliveries: _____ # of Abortions: _____ # of Miscarriages: ____ Age at 1st menses: ___ Frequency of menses: ______ Length of menses: _____ Date of last menses: _______ Date of last mammogram: _______ Do you have any concerns about your period or menopause? □ Yes □ No Please explain: ___________________________________ Have you ever had an abnormal pap smear? □ Yes □ No If circled yes, when was it? _______________________________________ Page 1 FAMILY HISTORY: Please indicate with a check (√) who in your family has had the following conditions. In the first column please indicate their living status. L = Living, D = Deceased, U = Unknown. High Living Asthma Diabetes Blood Heart Stroke Heart Cancer Colon Depression Other Status Pressure Disease Attack (Type) Polyps Mother Father Siblings Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Other Family Members Information: (please write in) SOCIAL HISTORY: Exercise: Drug Use: Alcohol Use Do you exercise regularly? □ Yes □ No Do you use any recreational drugs? Do you drink alcohol? □ Yes □ No Tobacco Use: □ Yes □ No If yes, # of drinks per week: __________ □ Current □ Never □ Former: quit on: ______ If yes please list ___________________ What type of alcohol: _______________ *If current # of packs/day ___ # of years ____ If you have used in the past, how long Is alcohol a concern for you or others who Other Tobacco: □ Pipe □ Cigar □ Snuff □ Chew have you been drug free? ________ surround themselves around you? Are you interested in quitting? □ No □ Yes Have you ever used needles for IV drug □ Yes □ No use? □ Yes □ No SAFETY SOCIOECONOMICS Do you wear a seatbelt regularly? □ Yes □ No Have you ever been physically or sexually Occupation:_________________________ Do you wear a bike helmet regularly? abused? □ Yes □ No Degree of education completed:_________ □ Yes □ No Do you have a gun in your home? Marital Status: _______________________ Do you feel safe at home? □ Yes □ No □ Yes □ No Spouse/Partner’s Name: _______________ Do you feel safe in your current relationship? Are you a member of a gang? □ Yes □ No Who lives at home with you? ___________ □ Yes □ No Other concerns: _____________________ ___________________________________ SEXUALITY Other Services Are you sexually active? □ Yes □ No Birth Control Method: _________________ Have you had a recent eye exam? □ Yes □ No Current sex partner(s) are: □ male □ female Have you ever had a sexually transmitted Have you had a recent dental exam? If sexually active do you practice safe sex? disease? □ Yes □ No □ Yes □ No □ Yes □ No If yes, please include: __________________ Do you see any other specialists? __________ Other Concerns: _____________________ Are you interested in being screened for ______________________________________ ___________________________________ sexually transmitted diseases? □ Yes □ No ______________________________________ EMOTIONS In the past year, have you had 2 or more weeks during which you felt sad or depressed; or you lost all interest or pleasure in things that you usually cared about or enjoyed? □ Yes □ No Have you had 2 or more years in your life when you felt depressed or sad most days, even if you felt okay sometimes? □ Yes □ No Have you felt depressed or sad much of the time in the past year? □ Yes □ No Do you ever feel like hurting yourself of others? □ Yes □ No Page 2 REVIEW OF SYSTEMS: Please indicate with a check (√) any current problems you have below. Constitutional Eyes Musculo-skeletal Fevers/chills/sweats Changes in vision Muscle/joint pain Unexplained weight loss/gain Farsighted Arthritis Fatigue/weakness Nearsighted Other: ______________________ Excessive thirst or urination Other: ______________________ ___________________________ Other: ______________________ ___________________________ ___________________________ Neurological Gastrointestinal Headaches Cardiovascular Abdominal pain Dizziness/light-headedness Chest pain/discomfort Blood in bowel movement Numbness Leg pain with exercise Nausea/vomiting/diarrhea Memory loss Heart murmur or heart problems Other: ______________________ Loss of coordination Palpitations ___________________________ Epilepsy or convulsive seizures Other: ______________________ Other: ______________________ ___________________________ ___________________________ Genitourinary Nighttime urination Chest Incontinence Psychiatric Breast lump/discharge Sexual function problems Anxiety/stress Other: ______________________ Discharge from penis Problems with sleep ___________________________ Other: ______________________ Depression ___________________________ Suicidal ideations Other: ______________________ Ears/Nose/Throat/Mouth ___________________________ Difficulty hearing/ringing in ears Gynecological Hay fever/allergies Abnormal vaginal bleeding Problems with teeth/gums Problems with conceiving Respiratory Difficulty swallowing Problems with contraception Cough/wheeze Difficulty with speech Vaginal discharge Difficulty breathing Other: ______________________ Vaginal odor Asthma ___________________________ Painful intercourse COPD Other: ______________________ Sleep apnea ___________________________ Other: ______________________ Endocrine ___________________________ Hypothyroid Hyperthyroid Lymphatic/Blood Abnormal hormone levels Unexplained lumps Skin Abnormal blood glucose levels Easy bruising/bleeding Rash or mole change(s) Other: ______________________ Anemia Psoriasis ___________________________ Other: ______________________ Eczema ___________________________ Other: ______________________ ___________________________ Page 3 .