Health History Form

All information will remain confidential

Name: Age: Date of Birth: Today's Date: SS#:

Gender: M F

Home Address: City: State: Zip:

Phones: Home#: Work#: Cell#:

Best time to reach?: AM PM

Best number to use: Home Cell Work

Primary language: English Spanish Other:

Employer Name: Employer Address:

Employer Phone #: Occupation: Shoe size:

Emergency contact name: Relationship: Phone:

If patient is a minor, please list

Father's Name: Father's Employer:

Mother's Name: Mother's Employer:

Insurance Information

Primary Insurance:

Company Name: Company Address: Phone:

Name of Policy Holder: Policy Holder's DOB: SS#:

Identification #: Group #: Copay: Type of Plan:

Secondary Insurance:

Company Name: Company Address: Phone:

Name of Policy Holder: Identification #: Group #:

Copay: Type of Plan:

Workers Compensation

If your employer/Workers Compensation Carrier has sent you for evaluation/treatment, please complete the following:

Type of injury sustained: (i.e. broken leg, back pain etc.):

Date of Injury: (required): Employer's name and address at time of injury:

Contact Name: Contact Phone #:

Workers Compensation Carrier: Address:

Contact Name: Contact Phone #:

Auto Accident

If you are here as a result of an automobile accident, then please fill out the following:

Date of Accident: Describe the injury and or pain that you have:

Auto Insurance Company: Address:

Phone #: Claim Number:

If we are filing your medical claims to your medical insurance company, please fill out the primary insurance information section above. Remember to submit your insurance card to the receptionist so that we may have a copy of your current insurance on record.

Assignment of Insurance Benefits And Authorization to obtain or release patient information

I hereby authorize the physician's office to release such information as may be necessary for claims to the insurance companies listed above. I also hereby authorize payment directly to the physician for any benefits otherwise payable directly to me, but not to exceed the regular charges for this period. I am financially responsible to the above physicians for charges not covered by the assignment. Patients not cover-ed by insurance are responsible at the time of service for charges incurred or arrangements for payment must be made with the business office.

I authorize the physician's office to release or obtain such information as may be necessary to assist in my medical treatment

Symptoms / Systems Review Check the symptoms your currently have or had in the past year
General: None Chills / sweats / fever Forgetfulness Headaches Unexplained weight loss Cardiovascular: None Chest pain Irregular Heart Beat Swelling of Ankles Respiratory: None Shortness of breath Wheezing Persistent cough Snoring Neurological/Mental Health: None Learning Disability Dizziness/Fainting Panic Attack Claustrophobia Emotional Illness Numbness / Tingling: Where?	Gastrointestinal: None Appetite poor Bowel changes Indigestion Nausea / Vomiting Rectal Bleeding Vomiting blood Genito-Urinary: None Blood in urine Frequent urination Lack of bladder control Painful urination Endocrine: None Heat or cold intolerance Excessive thirst Blood Disorders: None Bruise easily Prior Blood Transfusions	Eye: None Eye problems Blurred Vision Double vision Ear, Nose, Throat: None Ear problems Loss of hearing Loss of balance Hoarseness Difficulty swallowing Sinus problems Muscle/Joint/Bone: None Joint pain: Where? Difficulty walking Limited movement: Where? Skin: None Change in moles Rash Sore that won't heal Open wound	Men only: None Erection difficulties Lump in testicles Penis discharge Sore on penis Other Women only: None Bleeding between periods Breast lump / pain Extreme menstrual pain Nipple discharge Painful intercourse Other Date of last: Menstrual period Pap smear Mammogram Are you pregnant? Number of children Number of pregnancies Complications if any Other:
All Other Systems are Negative

Health Habits Check which substances you use and describe how much you use
Alcohol Illicit drugs Other Caffeine Tobacco

Occupational Concerns Check if your work exposes you to the following
Hazardous Substances Heavy lifting Stress Other Your occupation: Do you live with your family / spouse? If not, will you need assistance after your surgery?

Family History (Close blood relatives) Check all that apply
Heart Disease High Blood Pressure	Diabetes Tuberculosis	Cancer Type: Kidney Disease	Thyroid Disease Blood Disease	Neurological Mental Illness

Conditions / Past Medical History Check all that apply
Cardiac: None Congestive Heart Failure Heart Disease / Attack High Cholesterol High Blood pressure Mitral Valve Prolapse Valve Disease Pacemaker / ICD (Bring o Fractures implant card with you) Rhythm disturbances	Endocrine: None Diabetes Thyroid Problems / Goiter Adrenal disease Cancer or Tumor: None Type Chemo Radiation	Musculoskeletal: None Arthritis Gout Limited movement Multiple sclerosis Muscular dystrophy Back / neck problems Fractures Fibromyalgia Myasthenia Gravis	Bleeding / Circulation: None Anemia Bleeding tendency Blood clots / DVT Poor circulation Phlebitis Sickle Cell
Respiratory: None Asthma Bronchitis Emphysema / COPD Pneumonia Sleep Apnea CPAP TB	Genitourinary: None Kidney Failure Dialysis Kidney Stones Prostate/testicle problem Urinary Tract Infection	Skin: None Rashes: Where? Breast: None Lumps Nipple Discharge Breast Pain Abnormal Mammogram	Infectious Diseases: None History of Wound Infections Recent Mono HIV Hepatitis MRSA VRE C Diff
Neurological / Mental Health: None Stroke / Mini (TIA) Seizures Migraine headaches Chemical dependency Depression / Anxiety Paralysis Back Disc Disorder	Gastrointestinal: None Reflux Hernia Ulcers Hepatitis Liver disease	Hearing & Vision: None Hearing loss Glaucoma Cataract	Implantable Devices: None Ports/Pumps Other Important! Bring implant card with you.

Past Surgery Check all that apply
None Amputation Aneurysm (AAA) Angioplasty Appendectomy Arthroscopy Breast Biopsy Carotid	Cataract Colon Resection Cysto D & C Fem/Pop Bypass Gallbladder Heart Bypass Heart Cath	Heart Valve Hemorrhoidectomy Hernia Hysterectomy Kidney removal Laparoscopy Mastectomy Pacemaker / AICD	Prostate Sinus Spine (Back/Neck) Splenectomy Tonsils & Adenoids Total Hip Total Knee Tubal Ligation

Allergies Check all that apply
None	Penicillin Sulfa	Morphine Demerol	Novocaine Codeine	Iodine Aspirin	Latex Foods (List)	Adhesive/Tape
Other:

Medications List all medications with dosage you are currently taking (including 'over the counter,inhalers, eye drops, aspirin , herbs) or attach a list of your medications
Taken Prednisone / Steroids on regular basis in last year? Yes No Current Immunizations: Tetanus Pneumonia Flu

Anesthesia
Have you ever had anesthesia?	Yes	No	?	Comments:
Have you ever had a problem with anesthesia including malignant hyperthermia or difficulty-placing breathing tube?	Yes	No	?	Comments:
Has any member of your family had a problem with anesthesia?	Yes	No	?	Comments:
Loose, capped or broken teeth: bridges or dentures?	Yes	No	?	Comments:
Trouble opening mouth or jaw clicking?	Yes	No	?	Comments:
Do you have problems with limited neck mobility?	Yes	No	?	Comments:
Do you have shortness of breath after walking up 1 flight of stairs?	Yes	No	?	Comments:
Do you smoke?	Yes	No	?	# packs per day # years
Are you an ex-smoker? When stopped?	Yes	No	?	# packs per day # years
Do you drink alcoholic beverages?	Yes	No	?	How often How much
Do you use any street drugs?	Yes	No	?	Comments:
Have you ever had a blood transfusion?	Yes	No	?	If "yes", what year(s)?
Do you have problems with chronic pain?	Yes	No	?	Comments:
Any religious/cultural practices we should know about?	Yes	No	?	Comments:
Do you have an advanced directive (living will)?	Yes	No	?	Comments:
Females: Is there a chance you could be pregnant?	Yes	No	?	Comments:

Pharmacy Information:

Name of Pharmacy

Location Phone #

Other Physicians Please list all physicians that are presently treating you.
Primary Care Physician Office # Date Last Seen	Cardiologist Office # Date Last Seen

History of Present Illness
What is the reason for your visit? When did you first notice the problem? How did the problem begin? Have you had this problem before? Yes No Is the problem painful? Yes No Were you treated for this problem before? Yes No Location? Does it interfere with regular activities? Yes No Intensity of the pain: Character of the pain: Sharp Dull Constant Intermittent What makes it worse? What makes it better? Have you recently experienced: Fever Chills Nausea / Vomiting Weight loss Night sweats Comments:
Information provided by Relationship to Patient

History of Present Illness

Information provided by Relationship to Patient

How did you hear about the practice? (choose one) Internet/Google Friend/Family Doctor Referral (who?) Insurance Company Facebook Other