HEALTH HISTORY
Today’s date
Name
Birthdate
Reason for visit:
SYMPTOMS: (Circle symptoms related to today’s visit or, if here for a physical exam, check those you’ve had in past year)
GENERAL: Fever Chills Sweats Fatigue Sleep Problems
Weight Gain Weight Loss Depression Anxiety
EYES: Blurred vision Double vision Loss of vision Eye pain Eye Discharge Itchy Eyes
EARS/NOSE/THROAT: Earaches Ear Discharge Ringing in ears
Sore throat
Wear Glasses? Contacts?
Hearing loss Congestion Nosebleeds
Sinus pain/congestion
Difficulty Swallowing Hoarseness Dental problems Bleeding Gums
LUNGS/HEART: Cough
Coughing up blood
Chest pain
Shortness of breath Wheezing Irregular heart beat
GASTROINTESTINAL: Poor appetite Bloating Abdominal Pain Nausea/vomiting Diarrhea Constipation Indigestion Hemorrhoids
Rectal pain/itching/bleeding Have you had a colonoscopy? (year)
URINARY: Painful urination Frequency Urgency Blood in urine Incontinence (or lack of control) Recurring infections
MUSCULOSKELETAL: Painful joints Joint swelling Weakness Neck Pain Back Pain
NEUROLOGICAL: Headaches Dizziness/Vertigo Fainting spells Numbness
Tingling
Tremor
SKIN: Rash Itchiness Sores that will not heal Bruises Hives Change in moles
MEN ONLY: Breast lump Testicular lump Erection difficulties
WOMEN ONLY: Breast lump Breast pain Nipple discharge Irregular periods Painful periods Hot Flashes Night Sweats
Vaginal discharge Pain with intercourse Birth Control Method: Pill Ring Patch Condom Vasectomy Tubal IUD Other:
First day of last period:
Are you pregnant or planning to get pregnant in next 3 months:
Last pap smear:
Last mammogram:
Last bone density:
ALLERGIES: (Substance or medicine, Reaction)
MEDICATIONS/SUPPLEMENTS: (Name of medication, dose and how taken)
LYNN ALBERTSON ARNP, PS
13110 NE 177 PL STE B102
WOODINVILLE WA 98072
(425)415-8300
HEALTH HISTORY (continued)
HEALTH CONDITIONS:
Diagnosis:
Health Care Provider:
SURGERIES OR HOSPITALIZATIONS: (Procedure or reason, Approximate date/year)
PREGNANCY HISTORY:
Total pregnancies
Deliveries
Tubal
Miscarriages
Terminations
Children’s names and ages:
HEALTH HABITS:
Exercise: Type and times per week:
Diet: General description
Tobacco: Never
Former (packs/cans per day x # years
Current: (# packs/cans per day x # years
)
)
When did you quit?
Do you want to quit?
YES
Alcohol: (type and amount per day or week or year)
Other Substances Used: (type)
Do you want to quit (alcohol/other drugs)?
FAMILY HEALTH HISTORY:
Relation:
Age (if alive):
Age of death:
Health Conditions (or cause of death):
Father:
Mother:
Brothers:
Sisters:
Paternal Grandfather:
Grandmother:
Maternal Grandfather:
Grandmother:
REVIEWED BY: LYNN ALBERTSON ARNP
DATE:
NO