Health History Form
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Joy McCann Culverhouse Center for Swallowing Disorders University of South Florida COLLEGE OF MEDICINE Phone 813-974-3374 Fax 813-974-7031 MEDICAL HISTORY FORM NAME__________________________________________________ REFERRING DOCTOR_______________________ DATE OF BIRTH____/____/_______ AGE_____ SEX ______ PRIMARY DOCTOR_______________________ CHIEF COMPLAINT – THE MAIN REASON YOU ARE SEEING THE DOCTOR TODAY: check all that apply ____Difficulty Swallowing ____Painful Swallowing ____GERD-Heartburn-Indigestion ____Chest pain ____Weight loss ____Other _________________________________________ DESCRIPTION OF PROBLEM: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ PAST MEDICAL HISTORY: check all that apply ALS Dementia Head injury Muscular dystrophy Parkinson’s disease Myasthenia gravis Polio Myasthenia gravis Huntington’s disease Brain tumor/surgery Stroke (CVA) Other Cancer________________ Radiation therapy Chemotherapy Tracheostomy Arthritis Lung Disease Pneumonia or bronchitis Asthma Allergies (drugs, food, pollen, etc) Sleep Apnea Heart Attack Heart Disease High Blood Pressure Congestive Heart Failure Barrett esophagus Hiatal hernia Ulcers Diabetes Head & neck cancer Esophageal cancer HIV/AIDS Hepatitis Tuberculosis Autoimmune Disorder Collagen Vascular Disease Thyroid Disorder Other : ________________________ SURGERIES & HOSPITALIZATIONS ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ PERSONAL HISTORY: Never Alcohol use: Rarely Moderate Daily Tobacco use Never Previous, quit in year_________ Marital status: Single Married Widowed Occupation: ____________________________________ _ Patient label goes here Type of alcohol________________________ Current, packs/day_______How long? _________ Divorced Full time YEAR _______________________ _______________________ _______________________ _______________________ Separated Part Time Retired Disabled FAMILY HISTORY: Age if living Age at death Health problems or cause of death Mother Father Brother Sister Son Daughter REVIEW OF SYSTEMS Check box if you are currently experiencing: GENERAL Fever Chills Weight loss Change in appetite Anemia Fatigue Weakness Anxiety Depression EYES/EARS/NOSE/THROAT Change in vision Glasses or contacts Change in hearing Hearing aids Sinus problems Postnasal drip Chronic runny nose Difficulty swallowing Painful swallowing Lump in throat Regurgitation Dentures Change in saliva Recurrent sore throat Hoarseness RESPIRATORY Heavy Snoring C-PAP Machine Shortness of breath Asthma Emphysema Aspiration Pneumonia Bronchitis Cough Wheezing Coughing up blood CARDIAC Chest pain unrelated to meals Palpitations Heart murmurs Cardiac work-up w/in 1 year High cholesterol GASTROINTESTINAL Blood in stool Bowel changes Abdominal pain Nausea Vomiting Bloating GENITOURINARY Painful urination Blood in urine Discharge Frequent urination Urgency Frequent bladder infections Kidney stones Prostate problems ENDOCRINE Heat or cold intolerance -2- Excessive thirst Diabetes Thyroid disease MUSCULOSKELETAL Joint or muscle pain Muscle weakness in arms Joint swelling Osteoporosis Osteopenia NEUROLOGICAL Dizziness Fainting Seizures Headaches/migraines Balance problems Numbness/tingling in extremities Difficulty understanding speech Difficulty speaking Difficulty feeding yourself DERMATOLOGIC Lesions Rashes Skin cancer SLEEP HABITS Difficulty falling asleep Difficulty remaining asleep Night-time regurgitation Awakening due to heartburn Not rested after sleep Frequent waking to urinate Joy McCann Culverhouse Center for Swallowing Disorders University of South Florida COLLEGE OF MEDICINE Phone 813-974-3374 Fax 813-974-7031 Swallowing Questionnaire (Please complete only the sections that apply) Name_________________________________________Age _______Date_____________________ Swallowing complaints:______________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Duration of problem:_______________________________________________________________ Onset: sudden (date:____________) Frequency: every meal every day once a week Status: getting better Location: mouth gradual more than once a week once a month randomly getting worse throat staying the same esophagus combination Strategies to make swallowing easier: __________________________________________________ __________________________________________________________________________________ Factors or foods that worsen the problem:______________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Change in Weight: Current weight_________ Usual weight________ Current Diet level: regular soft puree liquids only tube feeding Nutritional Supplements: (Type and Amount)____________________________________________ Recent bronchitis or pneumonia: No Overall sense of well-being & energy level: Yes poor fair good Associated symptoms: Difficulty initiating a swallow Dental problems Can’t open mouth wide Can’t chew hard food Food gets stuck in mouth Food spread all over mouth Food falls out of mouth Drooling Too much saliva Dry mouth Changes in taste sensation Food comes out nose Weakness of oral muscles Food catches high in throat Food catches low in throat More difficulty with solids More difficulty with liquids Difficulty swallowing pills Cough/choke when swallowing Slow eater Worse late in day Worse when tired Changes in speech Changes in voice quality Patient label goes here -3- excellent Associated symptoms (continued): Poor/Inadequate nutrition Loss of appetite Loss of enjoyment of food Weight gain ( lbs) Weight loss ( lbs) “Lump” in your throat Sore throat Post nasal drip Frequent throat clearing Bad breath Reflux Throat pain when swallowing Chest pain when swallowing Heartburn or indigestion Bitter taste in mouth Worse with hot liquids Worse with cold liquids Food/liquids stick in chest or esophagus Regurgitation of food after meals Regurgitation of mucus Recent bronchitis or pneumonia Awaken with cough or choking Related Evaluations and Tests: X-Ray Swallowing Study_____________________________________________________ Primary Care Doctor_________________________________________________________ Ear Nose and Throat_________________________________________________________ Speech Pathology___________________________________________________________ Gastroenterology____________________________________________________________ Allergy____________________________________________________________________ Neurology__________________________________________________________________ Psychiatry__________________________________________________________________ Other_____________________________________________________________________ Please send a copy of today’s visit to the following medical providers: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ -4- Joy McCann Culverhouse Center for Swallowing Disorders University of South Florida COLLEGE OF MEDICINE Phone 813-974-3374 Fax 813-974-7031 HOME MEDICATION LIST ALLERGIES Please list all allergies to medication, food, x-ray dyes, iodine, etc. What are you allergic to? 1. 2. 3. 4. Reaction MEDICATIONS Please list ALL prescription and over-the-counter medication. Please include vitamins and herbal products you are currently using. Name of drug Strength # of tablets/caps How many/when? Reason taking 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Patient label goes here -5-
