NANCY LEFEBER HUGHES, M.D. Internal Medicine Associate 1515 Tremont – Galveston, Texas 77550 (409) 771-2040 __________________________________________ Name Date ADULT HEALTH HISTORY FORM Your answers on this form will help your health care provider better understand your medical concerns and conditions. This form will not be put directly into your medical chart. If you are uncomfortable with any question, do not answer it. If you cannot remember specific details, please provide your best guess. Thank you! Age ______ How would you rate your general health? __ Excellent __ Good ___Fair ___ Poor MAIN REASON FOR TODAY’S VISIT: ____________________________________________________________ OTHER CONCERNS: _______________________________________________________________________ REVIEW OF SYMPTOMS: Please check any current symptoms you have. Constitutional __ Recent fevers/sweats __Unexplained weight loss/gain __Fatigue/weakness Eyes __Change in vision Ears/Nose/Throat/Mouth __Difficulty hearing/ringing in ears __Hay fever/allergies/congestion __ Trouble swallowing Cardiovascular Lymphatic __Chest pains/discomfort Respiratory __Cough/wheeze __Coughing up blood Skin __Rash __New or change in mole Gastrointestinal __Heartburn/reflux __ Blood /change in bowel movement __ Nausea/vomiting/diarrhea __ Pain in abdomen Neurological __Headaches __Memory loss __Fainting Genitourinary __Painful/bloody urination __Leaking urine __Nighttime urination __ Discharge: penis or vagina __ Unusual vaginal bleeding __ Concern with sexual function Musculoskeletal __ Muscle/joint pain Psychiatric __ Anxiety __ Sleep problem Blood __ Unexplained lumps __Palpitations __Short of breath with exertion __Recent back pain Breast __ Breast lump __Nipple discharge __ Easy bruising/bleeding Endo __ Cold/heat intolerance __Increase thirst/appetite HAVE YOU RECENTLY HAD LITTLE INTEREST OR PLEASURE IN DOING THINGS, OR FELT DOWN, DEPRESSED OR HOPELESS? ___ YES ___ NO MEDICATIONS: List Prescription and non-prescription medicines, vitamins, home remedies, birth control pills herbs, etc. Medication Dose (e.g., Mg. /pill) How many times/day ALLERGIES OR REACTIONS TO MEDICATIONS: _________________________________________________________ DATE OF YOUR MOST RECENT IMMUNIZATIONS: Hepatitis A _____ Hepatitis B _____ Influenza (flu shot) _____ MMR _____ Pneumovax (pneumonia) _____ Meningitis _____ Tetanus (Td) _____ Varicella (chicken pox) shot or illness ____ Tdap (tetanus & pertussis) ____ HEALTH MAINTENANCE SCREENING TESTS: LIPID (CHOLESTEROL) DATE: _____ ABNORMAL? __YES __NO SIGMOIDOSCOPY OR COLONOSCOPY DATE: _______ ABNORMAL? __YES __NO WOMEN: MAMMOGRAM DATE: _____ ABNORMAL? __YES __NO PAP SMEAR DATE: _____ ABNORMAL? __YES __NO DEXASCAN (OSTEOPOROSIS) DATE: _____ ABNORMAL? __YES __NO MEN: PSA (PROSTATE) DATE: _____ ABNORMAL? __YES __NO PERSONAL MEDICAL HISTORY: Please indicate whether you have had any of the following medical problems (with dates) ___Heart disease: ___ High blood pressure ___High cholesterol specify type ____________________ ___Diabetes ___Thyroid problem ___Asthma/Lung disease ___Other (specify) _____________________________ ___Kidney disease ___Cancer (specify) ___________________________ SURGICAL HISTORY: Please list all prior operations (with dates) _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ FAMILY HISTORY: Please indicate the current status of your immediate family members: Please indicate family members (parent, sibling, grandparent, aunt or uncle) with any of the following conditions. Alcoholism__________________________________________ High cholesterol _________________________________ Cancer, specify type ________________________________ High blood pressure _____________________________ Heart disease________________________________________ Stroke ____________________________________________ Depression/suicide ________________________________ Bleeding or clotting disorder___________________ Genetic disorders __________________________________ Asthma/COPD ___________________________________ Diabetes ____________________________________________ Other _____________________________________________ Social History: OTHER CONCERNS Tobacco Use Caffeine Intake: __ none __Cigarettes __Never __Quit date ___________ Coffee/tea/soda ______ cups/day Current smoker: Packs/day _______# of yrs. _____ Weight: Are you satisfied with your weight? ____ Are you interested in quitting? ___________________________ Diet: How do you rate your diet? _ Good _ Poor __ Alcohol Use Do you eat or drink 4 servings of dairy or soy Do you drink alcohol? ___No ___Yes #drinks/wk. ___ daily or take calcium supplements? __ No __ Yes Is your alcohol use a concern for others? __No __ Yes Exercise: Do you exercise regularly? __ No __ Yes Drug Use What kind of exercise? ____________________________ Do you use any recreational drugs? ___No ___ Yes How long (minutes) _____ How often? ___________ Have you ever used needles to inject drugs? ___No ___Yes If you do not exercise, why? _____________________ Sexual Activity Safety: Do you use a bike helmet? ___ No ___Yes Sexually active ___ Yes ___ No ___ Not currently Do you use seatbelts consistently? ___ No ___ Yes Current sex partner(s) is/are: ___ Male ___Female Is violence at home a concern to you __ No __ Yes Birth control method ___________________ __ None needed Have you ever been abused? ____ No ___ Yes Have you ever had any sexually transmitted diseases? Have you had a gun in your home? ___ No ___ Yes STDS? ____ Yes ____No Are you interested in being screened for sexually transHave you completed a living will or durable mitted diseases? ___ No ___ Yes power of attorney for health care?___ No ___ Yes Socioeconomics Occupation: _____________________ Employer: ______________________________________________________ Years of education/highest degree: ____ Marital status: Single ___ Partner/Married ___ Divorced ___ Widowed ____ Other ____________ Number of children/ ages: _______________________________________________________________________________________________ Who lives at home with you? ____________________________________________________________________________________________ WOMEN’S HEALTH HISTORY # of pregnancies ______ # deliveries ____# abortions ____ # miscarriages _______ Age at start of periods: ___________________ Please check all conditions you currently have or have had and describe complications: General questions: Cardiovascular Angina Chest pain Murmurs Leg cramps Kidneys & Urinary Tract Blood in urine Brown urine Dribbling after urination Painful urination Musculoskeletal Anemia Arthritis Back pain Bursitis Excessive thirst Gout Anxiety Waking at night short of breath & getting out of bed. Ankle swelling Joint aches Headaches Cardiac Catheterization Depression Cold hands or feet Meningitis Congenital heart defects Dizziness when standing up quickly Heart attacks Involuntary urination/incontinence Frequent urination (day) Frequent urination (night) Urinary hesitancy Weak flow Easy bleeding Frequent bladder infections Kidney disease Kidney stone Easy bruising Endocrine Diabetes Sickle cell Muscle aches Gastrointestinal Diarrhea Abnormal body hair Changes in skin texture Cold intolerance Reflux Gallstones Ulcers Pleurisy – Wheezing Heat intolerance Heartburn Asthma History of “borderline” diabetes Increased hair loss Hepatitis Rheumatism Black tarry stools Thyroid disease Vomiting blood Constipation Nausea Weight loss Weight gain Change in sleep patterns Change in activity capacity Neurologic & Psychiatric: Paralysis Seizure Stroke Tingling Tremors Memory loss Fainting spells Dizziness Head injuries Black outs or near blackouts Change in sensation anywhere in body Localized weakness or numbness Ears, Eyes, Nose & Throat Hay fever Glaucoma Polyps Heart failure High or low blood pressure Irregular heart beat Purple fingers or lips Leg pain that resolves with rest Heart palpitations Varicose veins Respiratory Breathlessness when lying flat Prolonged cough Coughing up blood Emphysema Abnormal blood counts Blood clots in legs/lungs Bone Marrow Biopsy Joint swelling Morning stiffness Anal fissures Allergy Cataracts Shortness of breath Tuberculosis Male & Female Painful sexual intercourse Loss of sexual interest Unprotected sex Problems swallowing Hiatal hernia Goiter Hoarseness Double vision Gum problems Pneumonia Frequent infections (bronchitis) Skin Abscess Groin itching Sexually transmitted diseases Males only Hernia Sterility Hemorrhoids Red blood after bowel movements Females Only D&C Hot flashes Eye problems Ear infections Glasses/contacts Acne – Oily skin Dandruff Boils – Rashes Hearing loss Ear discharge/pain Hives Dry skin/Psoriasis Hernia Fibroids Jaundice Bloody ejaculation Inability to complete intercourse Lump on testicle Frequent nosebleeds Ringing in your ears Athlete’s foot Penile discharge Sinus infections Swollen glands Excessive body odor Excessive sweating Fungal infections Premature ejaculation Problems maintaining or keeping an erection Prostate disease Nail problems Moles – irregular Sores on penis or warts Testicular pain Moles – change/new Testicular swelling Provider notes: Intestinal Obstruction Liver disease Abnormal bleeding between cycles Complications with pregnancy PMS - Endometriosis Heavy bleeding during cycles Discharge from breast Ovarian cysts Pelvic Inflammatory Disease Postmenopausal symptoms Vaginal discharge Vaginal dryness Vaginal warts