Patient History and Assessment
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Oldendorf Medical Services, PLLC Mark Oldendorf, MD Corina Gonzales, MD Michelle Cafaro, RPA Jenna Hafner, PA-C Bill Lynch, PA-C Comprehensive Health Assessment Name: Date of Birth: _________ Gender: M F Date: What are your health goals for the next year? Where were you receiving care before? Are there obstacles that prevent you from taking care of your health?_________________________________________ ____________________________________________________________________________________________________ Immunizations (Check off any vaccinations you have had. Add year, if known.): Tetanus (Td) ____ HPV ____ With Pertussis (T dap) ____ Varicella (Chicken Pox) shot or illness ____ Pneumovax (pneumonia) ____ Polio ____ Influenza (flu shot) ____ Hepatitis A ____ Hepatitis B ____ MMR ____ Meningitis ____Zostavax (shingles) ____ Family, Cultural, Social Assessment: Are you a single parent? Yes □ No □ Are you employed? Yes □ No □ Are you the care giver of a family member? Yes □ No □ Have there been any major changes in your life you would like to make us aware of? _____________________________________________________________________________________ Communication needs: Do you require special accommodations for: Hearing Impairment: Yes □ No □ Visual Impairment: Yes □ No □ Interpreter needed: Yes □ No □ Please Describe: ________________________________________________________________________ Medical History List Specialists- Include self-referred specialist: ___________________________________________________________ ____________________________________________________________________________________________________ Surgeries, Tests and/or Illnesses: ____________________________________________________________________________________________________ Medical History of Parent, Sibling or Children (ex: Diabetes, Cancer Heart Disease, Stroke):_____________________________________________________________________________________________ ____________________________________________________________________________________________________ Have you had a: Colonoscopy? Yes □ No □ If yes, when? Dexa Scan (bone density)? Yes □ No □ If yes, when? Women’s Health History: Date of last mammogram: Age you started menstruation: Age you started menopause: Date of last Pap smear: Last Period: GYN Name: _____________ Men’s Health History: Do you do a testicular exam? Yes □ No □ Date of last Digital Rectal Exam: ______ PSA _____ Allergies: (List any reactions you have had) Medications: (List all medications including non-prescription) Advance Care Planning: Do you have a Health Proxy: Yes □ No □ Do you have an Advance Directive: Yes □ No □ Do you have a Do Not Resuscitate Document (DNR): Yes □ No □ General Health Habits Do you suffer from gum disease? Do you have regular dental check ups? Do you use seat belts? Yes: ___ No: ___ Yes: ___ No: ___ Yes: ___ No: ___ 1365 Washington Avenue Suite 100 Albany, New York 12206 Office: (518) 435-1300 Fax: (518) 435-1397 Oldendorf Medical Services, PLLC Mark Oldendorf, MD Corina Gonzales, MD Michelle Cafaro, RPA Jenna Hafner, PA-C Bill Lynch, PA-C Comprehensive Health Assessment Do you practice safe sex? Yes: ___ No: ___ Have you had multiple sex partners in the past year? Yes: ___ No: ___ Do you use sunscreen? Yes: ___ No: ___ Does your home have smoke detectors? Yes: ___ No: ___ Do you exercise on a regular basis? Yes: ___ No: ___ How often?__________________________ Do you feel tired or have low energy? Yes: ___ No: ___ Has your appetite or weight changed? Yes: ___ No: ___ Describe____________________________ Do you eat a diet high in fiber? Yes: ___ No: ___ Do you eat foods known to be high in cholesterol such as red meat and dairy? Yes: ___ No: ___ Do you use tobacco? Yes: __ No: ___ How often?__________________________ Are you a prior smoker? Yes: __ No: ___ Quit date?___________________________ Are you exposed to second hand smoke? Yes: ___ No: ___ Do you use caffeine? Yes: ___ No: ___ How often?__________________________ Do you use alcohol? Yes: ___ No: ___ How often?__________________________ Do you use street drugs? Yes: ___ No: ___ What kind?__________________________ Do you or a family member have a mental health or substance abuse problem that you would like to discuss? _____________________________________________________________________________________________________ Depression Screening: In the past 2 weeks, have you been bothered by: Little interest or pleasure in doing things? Yes □ No □ Feeling down, depressed, or hopeless? Yes □ No □ Have you had poor appetite or experienced overeating? Yes □ No □ Trouble falling asleep, staying asleep or sleeping too much? Yes □ No □ Review of Symptoms: Please mark the box and/or circle any persistent symptoms you have had in the past few months. Read through every section and check “no problems” if none of the symptoms apply to you. General Respiratory Hematologic/Lymphatic __ Unexplained weight loss/gain __ Cough/wheeze __Swollen glands __ Unexplained fatigue/weakness __ Loud snoring/altered __Easy bruising __ Fall asleep during the day when sitting breathing during sleep __ No problems __ Fever, chills __ Short of breath with exertion Neurological __ No problems __ No problems __ Headaches Skin Gastrointestinal __ Memory loss __ New or change in mole __ Heartburn/reflux/indigestion __ Fainting __ Rash/itching __ Blood or change in bowel __ Dizziness __ No problems movement __ Numbness/tingling] Breast __ Constipation __ Unsteady gait __ Beast lump/pain/nipple discharge __ No problems __ Frequent falls __ No problems Genitourinary __ No problems Ears/Nose/Throat __ Leaking urine Allergic/Immune __ Nosebleeds, trouble swallowing __ Blood in urine __ Hay fever/allergies __ Frequent sore throat, hoarseness __ Nighttime urination increased __ Frequent infections __ Hearing loss/ringing in ears frequency __ No problems __ No problems __ Discharge: penis or vagina Psychiatric Eyes __ Concern with sexual function __ Anxiety/stress/irritability __ Change in vision/eye pain/redness __ No problems __ Sleep problem __ No problems Musculoskeletal __ Lack of concentration Cardiovascular __ Neck pain __ No problems __ Chest pain/discomfort __ Back pain Women only __ Palpitations (fast or irregular __ Muscle/joint pain __ Pre-menstrual symptoms heartbeat) __ No problems (bloating, cramps, irritability) __ No problems Endocrine __ Problem with menstrual __ Heat or cold sensitivity periods __ No problems __ Hot flashes/night sweats __ No problems 1365 Washington Avenue Suite 100 Albany, New York 12206 Office: (518) 435-1300 Fax: (518) 435-1397
