Adult Male
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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
