ADULT HISTORY: MALE
Date:
Patient Name:
DOB:
PAST MEDICAL HISTORY: (PMH)
Unremarkable
Alzheimer’s Disease
Anemia
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Autoimmune Disorder
Blood Transfusions
Brain Tumor
Cataract
Cancer - Breast
Cancer – Colon
Cancer – Lung
Cancer – Prostate
Cancer – Skin
Cancer – Thyroid
Chrohn’s Disease
Chronic Low Back Pain
Cirrhosis
Congestive Heart Failure
Constipation, Chronic
COPD
Coronary Artery Disease
CVA/Stroke
Degenerative Joint Disease
Dementia
Depression
Diabetes Type 1
Diabetes Type 2
Diverticulitis
DVT (Clot)
Eczema
Fibromyalgia
GERD (gastric reflux)
Glaucoma
GI Bleed
Gout
Hepatitis A
Hepatitis B
Hepatitis C
Hyperlipidemia
Hypertension
Hyperthyroidism
Hypothyroidism
Incontinence
Infertility
Inflammatory Bowel Disease
Kidney Disease
Kidney Stone
Liver Disease
Lupus
Macular Degeneration
Migraine Headache
Multiple Sclerosis
MI (Heart Attack)
Osteoarthritis
Osteopenia
Osteoporosis
Parkinson’s Disease
Peptic Ulcer Disease
Polymylagia Rheumatica
Psoriasis
Polymylagia Rheumatica
Rheumatoid Arthritis
Seizure Disorder
Tuberculosis
Urinary Tract Infections, Recurrent
Varicose Veins
Other:
September 8, 2011
Page 1 of 4
ADULT HISTORY: MALE
Date:
Patient Name:
DOB:
PAST SURGICAL HISTORY: (PSH)
DATE
Unremarkable
Abdominal Aortic Aneurysm Repair
Abdominal Surgery
Amputation
Anesthesia Problem – No
Anesthesia Problem - Yes
Aortic Valve Replacement
Appendectomy
Aorto-Femoral Bypass
Arthroplasty – Total Hip Replacement
Arthroplasty–Total Knee Replacement
Arthroscopy – Scoping of Knee
Back Surgery
Breast Biopsy
Breast Surgery
Bronchoscopy (Scoping of Lungs)
CABG – Coronary bypass surgery
Carotid Endarterectomy
Carpal Tunnel
Cataract(s) Removed
Cholecystectomy (Gallbladder Removed)
Cholecystectomy (Gallbladder Removed)
Circumcision
Colon Resection
Colostomy
Craniotomy
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
DATE
Gastric Bypass
Hemorrhoidectomy
Hernia – Incisional
Hernia – Inguinal
Hernia – Umbilical
Hernia – Ventral
Laminectomy
Lap Band Procedure
Mitral Valve Replacement
Kidney Transplant
Pacemaker
Pacemaker with ICD Placement
Parathyroidectomy (Parathyroid Removed)
Pneumonectomy (Lung Removed)
Prostatectomy (Prostate Removed)
PTCA (Heart Stent)
Rotator Cuff Repair
Sinus Surgery
Surgical Complication
Tonsillectomy
TURP
Urinary Incontinence Surgery
Vascular Surgery
Vasectomy
Vein Stripping
Other:
Medications and How You Take Them (Include vitamins and herbals):
Name:
Strength:
Name:
Strength:
Name:
Strength:
Name:
Strength:
Name:
Strength:
Name:
Strength:
Name:
Strength:
Allergies:
Y
September 8, 2011
Amount/day:
Amount/day:
Amount/day:
Amount/day:
Amount/day:
Amount/day:
Amount/day:
N If yes, please list:
Page 2 of 4
ADULT HISTORY: MALE
Date:
Patient Name:
DOB:
FAMILY HISTORY: (FH)
FH Unknown
FH Alcoholism
FH Anemia
FH Anesthetic Complications
FH Angina
FH Anxiety
FH Arthritis
FH Asthma
FH Birth Defects
FH Bleeding Disease
FH Breast Cancer
FH Coronary Heart Disease – Male <55
FH Coronary Heart Disease – Female <65
FH Cervical Cancer
FH Colon Cancer – Father
FH Colon Cancer – Mother
FH Colon Cancer
FH Depression
FH Diabetes
FH Endometriosis
FH Growth/Development
FH Headaches
FH Heart Disease
FH Hypertension
FH High Cholesterol
FH Kidney Disease
FH Lung Cancer
FH Lung/Respiratory
FH Melanoma
FH Migraines
FH Osteoporosis
FH Other Cancer (Specify Below)
FH Ovarian Cancer
FH Premenstrual Syndrome (PMS)
FH Psychiatric Care
FH Seizures
FH Severe Allergies
FH Stroke
FH Thyroid Problems
FH Uterine Cancer
FH Weight Disorder
FH Other Medical Problems (Specify Below)
Other:
SOCIAL HISTORY: (SH)
Married
Divorced
Separated
Single
Widowed
1 Child
2 Children
3 Children
4+ Children
September 8, 2011
History of Domestic Abuse
Religion Affecting Care
Passive Smoke Exposure
Military Service
Service Disability
Other Disability
Page 3 of 4
ADULT HISTORY: MALE
Date:
Patient Name:
DOB:
RISK FACTORS: Please answer the following questions in order to better assess your health risk
factors.
Tobacco Use:
Currently Smoking:
Cigarettes
Cigars
Smokeless/chewing
Amt: ______ packs/day
Amt: ______ # per week
Amt: ______ per day
Previous Smoker:
Year Started: ____________
Year Quit:
____________
Pack-Years: ____________
Comments:
Never Smoked
Passive Smoke Exposure (Second Hand Smoke):
Drug Use:
Yes
No
None
If Yes: Substance Type:
Other:
Comments:
Marijuana
HIV High Risk Behavior:
Yes
Alcohol Use:
Yes
No
Drinks per Day:
<1
1
Cocaine
Crack
Heroin
Illegal Prescription Drugs
No
2
3
4
4+
If Yes: Type
Caffeine Use: Drinks per Day:
Exercise: Times per Week
Seat Belt Use:
Sun Exposure:
September 8, 2011
0
1
1
2
2
3
Percentage of Time Used:
Frequently
3
4
4
5+
5
100
Occasionally
6
75
7
50
8+
25
0
Rarely
Page 4 of 4