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Personal Health History Form Demographic Information Name _last

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Personal Health History Form Demographic Information Name _last Powered By Docstoc
					PERSONAL HEALTH HISTORY FORM DEMOGRAPHIC INFORMATION
Name (last, first, middle initial) Home Address City Home Phone Age Sex F M Marital Status M S D Social Security Number State Work Phone Employer Birth date Zip Code Cell Phone Job Title

Email Address Emergency Contact (Name)/relationship Personal Physician Preferred Pharmacy

How did you learn about us / Referred by: Contact (phone 1) Physician Fax Pharmacy Fax Contact (phone 2) Physician Phone Pharmacy Phone

REASON FOR CONSULTATION
What health concerns and symptoms bring you to our office? Please be specific.

What would you most like to achieve with this health consultation?

MEDICAL HISTORY
Please check any condition that you currently have or have had in the past. Headaches (migraines, other) Yes No Heart disease Yes No
Seizures disorder Recurrent sinus Infections Seasonal allergies Psychiatric/emotional illness Depression Anxiety or excessive stress Asthma Chronic bronchitis Lung or breathing problems Chronic indigestion Stomach ulcers Intestinal disease Skin problems/dermatitis Back pain or sciatica Herniated disc Neck pain Chronic muscle or joint pain Carpal tunnel syndrome Fibromyalgia Diabetes Thyroid disease Osteoporosis/osteopenia

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No No No No No No No No No No No

Chest pain Irregular heart beat High blood pressure Blood clotting problems Bleeding disorder Stroke/vascular disease Constipation/diarrhea Hepatitis/liver disease Kidney disease Menstrual disorders Reproductive problems Prostate problems Sexual/libido problems Tendonitis Chronic pain problems Shoulder pain Osteoarthritis Rheumatoid arthritis Artificial joint/implants Cancer Psoriasis or eczema Insomnia

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No No No No No No No No No No No

Provide explanations and list any additional health problems below:

List any surgeries/operations you have had and the year you had them:

Year

Surgery/Operation

Are you currently under the care of a health professional for any medical condition? Yes No If yes, please provide name and explain condition and treatment (Note: Do not put meds here)

List any medications you are currently taking or have taken in the recent past. Medication Name Date Started Date Stopped Dosage (amount/# daily)

List any vitamins, herbs or nutritional supplements that you are taking. Medication Name Date Started Date Stopped Dosage (amount/# daily)

List any medication allergies that you are aware of:

List any environmental/food allergies that you are aware of:

Preventive Tests History Month/Year of last test Cholesterol Bone density Colonoscopy Exercise stress test Test Results

MEDICAL HISTORY – FEMALE (MEN, PLEASE SKIP TO NEXT PAGE)
Are you currently pregnant? Yes No First day of last cycle? How many children? Yes No Yes No No How many pregnancies have you had? Do you perform monthly self breast exams? Had a hysterectomy? Yes

If yes, were your ovaries removed? Has your abdominal girth and weight been increasing? Yes No Have you had any menstrual irregularities? Yes No

If yes, explain below:

Are you taking or have you taken hormones or oral contraceptives Yr Started Yr Stopped

Yes

No

If yes, please list all hormones and oral contraceptives you have taken below: List hormones or contraceptives here

Have you ever had any problems or concerns about taking hormone replacement therapy? Yes No If yes, explain below:

Month/Year of last test Pap/pelvic exam Breast exam Mammogram

Test Results

Please check those conditions that you currently have or have had in the past Condyloma Memory lapse Yes No Yes No
Decreased libido Dizzy spells Painful or difficult urination

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No

Menopause Dribbling Mood swings Frequent nightime urination Pelvic pain Painful intercourse Frequent urination Excessive itching
Sexually transmitted disease Sore breasts Vaginal dryness Vaginal itching

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No

Excessive urination
Hair growth on face Hair loss Blood in urine Hot flashes Irritability Snoring Stress incontinence Urge incontinence

Recurrent UTI’s Vaginal discharge

Yes Yes

No No

Vaginal odor Weird dreams

Yes Yes

No No

Explain yes answers below as needed:

MEDICAL HISTORY – MEN ONLY
Date of last prostate exam Are you concerned with loss of muscle mass, tone or strength Do you perform periodic testicular self examination Has your abdominal girth and weight been increasing
Benign prostate hypertrophy Circumcism Decreased libido Condyloma Dribbling Painful urination Bed wetting Erectile dysfunction Frequent urination Blood in urine

Yes Yes Yes

No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No

Hesitancy (urination) Incontinence Frequent nightime urination Prostate cancer Prostate problems Sexually transmitted disease Swelling of penis Testicular pain or swelling
Uretheral discharge Recurrent urinary tract infections

Explain yes answers below as needed:

FAMILY HISTORY
Mother living? Father living? Family disease history Heart disease High blood pressure Diabetes Arthritis Skin disorders Breast cancer Uterine/Ovarian Cancer Prostate cancer Colon cancer Other cancer Yes Yes No No If no, provide age at death If no, provide age at death Write relationship of the relative(s) with the disease on the adjacent lines Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No

List any other diseases/conditions in the family and the relationship

SOCIAL HISTORY
GENERAL
Overall health Physical fitness level

Excellent Excellent Yes No Yes No

Good Good

Fair Fair

Poor Poor Yes No Yes No

Under a lot of stress

Fatigued all the time Yes No

Having difficulty dealing with stress

Often sad and blue

Practice meditation or other relaxation techniques Dietary Habits No special dietary habits Try to eat a healthy diet

True True

Avoids red meat Min carbs True True Chocolate

Yes True

Minimizes fat Vegetarian

True True True Yes Yes Yes

Emphasize fruits, grains and vegetables Commonly eat at fast food restaurants Commonly consume: Coffee Commonly consume: Candy Exercise Habits No special exercise habits Aerobic exercise: Jog Stretch/Yoga/Tai Chi Yes Yes

Avoids dairy/cheese Commonly eat chocolate Yes Yes Diet soda Chips

Regular soda

True True True

Routinely exercise Walk True week Treadmill True Other Lift weights

hrs True
Swim

x/week True

Tobacco Use I never smoked cigarettes or chewed tobacco I now smoke I quit smoking in (mo/yr) Alcohol Use I never drink alcohol of any kind I regularly drink: 1-2 drinks/day Over 4 drinks/day True

True

I smoke cigars/pipes

True years. Yrs.

packs of cigarettes per day. I have smoked for I smoked packs/day for s m o True I drink occasionally or socially k True e Over 2 drinks/day True d drink (wine, beer, other) I typically

True

Hobbies/Sports/Recreation List routine hobbies/sports/recreational activities:

______________________________________ Patient Signature

________________ Date

Methods of completing and submitting this form:  You may complete this form in ink, sign it and fax it to us at (888) 205-7932.  You may complete this form on your computer using Microsoft Word, type your name in the signature box and submit it via fax as above or via the Proactive Secure Portal. This HIPAA-compliant portal provides encrypted email over SSL to ensure absolute security and privacy. To use the secure email feature, go to www.proactivesecureportal.com, register using the on-screen registration instructions and send a secure email to andre@proactivesecurept.com. PLEASE DO NOT SUBMIT THE FORM BY ORDINARY EMAIL. Note: To meet the needs of all of our patients, we require as much advance notice of cancellation as possible. If your cancellation is less than 48 hours prior to your appointment or you do not show, your credit card will be charged for the appointment and a rescheduling fee may apply. Our complete cancellation policy is provided on our web site at www.proactivewellness.com. Click on fees and payment.


				
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