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Michael W. Conway, M.D.
Michael C. Kilpatrick, M.D.
Randall D. Brown, M.D.
David J. Hartung, D.O.
Derek A. Oldham, M.D.
Terri J. Agan, RNC NP-C
Bret A. Cornn, MMSC, PA-C
Rhonda L. Fountain, NP-C
1124 Medical Place
Seymour, Indiana 47274
Tel: 812-522-1613
Fax: 812-522-6694
JACKSON PARK PHYSICIANS
Adult Patient Health History Form
Name:
Gender:
Date of Birth:
M
F SSN:
Today’s Date
MEDICATIONS Prescription, over the counter medicines, vitamins, home remedies, herbs, etc.
Medication
Dose (mg/pill, units, etc)
Frequency (times/day)
(List additional medications on reverse of sheet if necessary. Please bring a current medication list to
each office visit.)
ALLERGIES List all allergies to medications, dyes, other:
None
Latex Allergy
HEALTH MAINTENANCE SCREENING TESTS:
Sigmoidoscopy
Colonoscopy
Endoscopy
Last Eye Exam:
Date
Last Dental Exam:
Date
Women:
Mammogram
Date
Pap Smear
Date
Dexascan (osteoporosis screen) Date
Men:
PSA (prostate screen)
Date
Date
Normal? Yes or No
Normal?
Normal?
Normal?
Normal?
Yes
Yes
Yes
Yes
No
No
No
No
WOMEN’S HEALTH HISTORY If applicable, please indicate:
# Pregnancies
# Deliveries
# Miscarriages
# Abortions
Age at first period
Date of last period
Age of menopause
Self breast exams?
Breast implants?
Leakage of urine?
Yes
Yes
Yes
No
No
No
PERSONAL
MEDICAL HISTORY
HAVE YOU EVER HAD ONE OF THE
FOLLOWING: (MARK X)
Measles
Mumps
Chickenpox
High Cholesterol
Kidney Disease
Pneumonia
Anemia
Thyroid Problems
Migraine Headaches
Diabetes
Cancer
Hernia
High Blood Pressure
Depression/Anxiety
Asthma/Lung Disease
Hives
Eczema
Any other disease, please list:
PREVIOUS HOSPITALIZATION/SURGERIES
DATE
HOSPITAL, CITY, STATE
SPECIALISTS: List any current or previous specialists including their name, address and phone number.
List additional specialists on reverse of sheet if necessary.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
FAMILY HISTORY Please indicate if any of your immediate family members have any of the following
conditions:
Alcoholism
Cancer
Heart Disease
Depression
Anxiety
Diabetes
High Cholesterol
High Blood Pressure
Stroke
Asthma
COPD
Bleeding or clotting disorder
Other
SOCIOECONOMICS Please indicate:
Occupation
Employer
Education
Grade school
High school
College
Graduate school
Marital Status
Single
Married
Divorced
Separated
Use of Alcohol
Never
Rarely
Moderate
Daily
Use of Tobacco
Never
Previously, but quit___________ Current Packs/Daily _________
Have you ever used needles to inject drugs?
No
Yes
Spouse/ Partner’s Name
Names of Children/ Ages
________________________________
_____________________________________________________________________________________
Other
Please indicate:
Do you have a designated Power of Attorney for Health Care?
Yes
No If yes, please provide a copy.
Do you have a living will?
Yes
No If yes, please provide a copy.
Do you have any religious beliefs that might impact your health care? Yes No
If yes, please describe.
_____________________________________________________________________________________
_____________________________________________________________________________________
So that Jackson Park Physicians can best serve my medical needs, I have completed this questionnaire as
completely as possible. I understand that the Patient/Health Care Provider relationship is built on trust
and honesty. By completing and signing this form, I acknowledge that any intentionally false
information could seriously affect my health.
Printed Name:
Signature:
Date: