HDSA Center of Excellence at UC Davis Medical Center
Rev 10/2013
HD CLINIC MEDICAL HISTORY FORM
Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the
questions below as best as you can. If you need assistance, a caregiver/companion may complete this
form for you.
Appointment Date:
DEMOGRAPHICS:
Name:
Date of Birth:
Height:
Current Weight:
Please answer the following questions:
Are you Right Handed?
Are you Left Handed?
Education Completed:
Yes
No
Grade (K-12)
College
Number of years:
Graduate school
Degree:
Degrees
Please list:
Employment:
Yes
No
Full-Time Work
Number of Hours per
week:
Full-Time Occupation
Part-Time Work
Number of Hours per
week:
Part-Time Occupation
Unemployed
Date you last worked:
Occupation at last job:
Applied for OR
Receiving Disability
Benefits
HDSA Center of Excellence at UC Davis Medical Center
Please describe type
(Social Security, etc)
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HDSA Center of Excellence at UC Davis Medical Center
Rev 10/2013
Marital Status:
Yes
No
Single
Married
How long?
Divorced
How long?
With partner
How long?
FAMILY HISTORY:
Are they living?
Yes
No
Are/were they
affected with HD?
Yes
No
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Siblings (list name and age)
1.
2.
3.
4.
5.
6.
7.
8.
Children (list name and age)
1.
2.
3.
4.
5.
6.
7.
8.
Other persons affected with HD in your family not listed above?
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HDSA Center of Excellence at UC Davis Medical Center
Rev 10/2013
CURRENT MEDICATIONS:
Please list all current medications, either prescribed or over-the- counter (may
attach list if you have brought one)
Please list any known allergies: (i.e. Medication, Food, Environmental, etc.):
SOCIAL HISTORY:
Yes
No
Yes
No
Do you live alone?
If no, with whom do you live?
Do you exercise regularly?
Please describe the exercise you participate in? Be sure to
include how often.
Yes
Do you drink alcohol?
No
How often?
--Number of drinks per week?
Do you smoke cigarettes, tobacco, pipes or
cigars?
Number of
packs/cigars per
day?
--How long have you been smoking?
Do you use cannabis (marijuana) or any
recreational drugs?
If yes, please list:
HDSA Center of Excellence at UC Davis Medical Center
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HDSA Center of Excellence at UC Davis Medical Center
PAST MEDICAL/SURGICAL HISTORY:
Have you ever been diagnosed with any of the following?
Yes
No
Rev 10/2013
Date Diagnosed?
High blood pressure
Diabetes
Heart Attack
Stroke
Heart Failure
Blood vessel disease
High cholesterol or lipids
Tuberculosis
Immunodeficiency disorder
Hepatitis
Cancer
Respiratory illness
Bleeding problems
Leg clots
Peptic Ulcer disease
Kidney or urinary problems
Arthritis
Skin conditions
Seizures
Traumatic Brain Injury
For women, any gynecologic
issues?
For men, any prostate or urologic
issues?
Have you ever had an injury or
illness requiring hospitalization:
If so , describe
Have you ever had surgery?
Please list year(s) and reason for surgery(s)?
HDSA Center of Excellence at UC Davis Medical Center
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HDSA Center of Excellence at UC Davis Medical Center
Rev 10/2013
For Females:
Yes
No
Have you ever been pregnant?
--Number of Pregnancies
--Number of Deliveries
Any complications due to pregnancy?
Please describe?
Are you still capable of pregnancy?
Are you using any form of birth control?
Year of Menopause?
MENTAL HEALTH HISTORY:
Have you ever received medicine, counseling or been hospitalized for:
Yes
No
Depression
Anxiety
Obsessive Compulsive Disorder
Psychosis
Suicidal Thoughts
Suicidal Attempt
REVIEW OF SYSTEMS:
Yes
No
Have you been diagnosed with HD?
What year were you diagnosed
and where were you diagnosed?
Yes
No
What were your FIRST symptoms?
Motor (movement problems)
Cognitive (thinking problems)
Psychiatric (mood or behavioral
problems)
Mixture of the above symptoms
Other symptoms
What age did you FIRST experience
symptoms
What symptoms did your affected
parent have and at what age did
they occur?
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HDSA Center of Excellence at UC Davis Medical Center
Please answer YES or NO for the following questions:
Yes
No
General:
Yes
No
Respiratory:
Weight Gain/Loss of more than 5 lbs
over the last several months?
Short of breath on exertion?
Loss of Appetite?
Walk 2 flights of stairs w/out
significant discomfort?
Fever or Chills?
Have frequent yellow/green
sputum?
Feel weak and tired?
Cough up blood?
Skin:
Cardiovascular:
Do you have rashes, bruises?
Chest pain, tightness, angina of
the chest on exertion?
Skin Discoloration?
Chronic ankle swelling?
Bleeding/easy bruising tendency?
Can you sleep flat in bed?
Head:
Do you wake up at night short of
breath?
Do you have tenderness?
Gastrointestinal:
Lumps or masses?
Nausea or vomiting?
Eyes
Diarrhea or constipation?
Pain or discharge?
Black tarry stools or bloody
stools?
Change in Vision
Heartburn or reflux?
Ears:
Genitourinary:
Hearing problems?
Cloudy or bloody urine
Pain or discharge
Burning on urination
Nose:
Get up several times at night to
urinate?
Frequent nose bleeds?
Men: Hard to initiate/maintain
urination?
Trouble breathing through nose?
Central Nervous System:
Pain or discharge?
Any seizures?
Mouth & Throat:
Severe headaches?
Dental Disease?
Loss of strength or sensation?
Hoarseness or voice changes?
Memory changes?
Sore throat or other pain?
Other neurologic problems?
Lumps, masses, discharge?
Arthritis or joint problems?
HDSA Center of Excellence at UC Davis Medical Center
Rev 10/2013
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HDSA Center of Excellence at UC Davis Medical Center
Rev 10/2013
PRIMARY CARE DOCTOR:
Name:
Address:
Contact Phone Numbers:
PSYCHIATRIST OR PSYCHOLOGIST:
Name:
Address:
Contact Phone Numbers:
NEUROLOGIST:
Name:
Address:
Contact Phone Numbers:
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