Channel Islands Family Practice and Urgent Care

PATIENT HISTORY


Name:____________________________ Age:______ D.O.B.________ Date:________


Current Medications: Allergies:

________________________________________ ___________________________

________________________________________ ___________________________

Past Medical History:

Last eye exam:__________ Last Dental Exam:________Last Physical Exam:_________

Tetanus Vaccine:________ (recommend booster every 10 years)

Flu vaccine:____________ (recommend yearly for high risk and over 65)

Pneumonia vaccine:______ (recommend age 65 and over every 7 years)

Hepatitis B vaccine:______ (recommend children and high risk adults)

Hepatitis A vaccine:______ (recommend for travel outside US and high risk)

Sigmoidoscopy: _________ (recommend every 3-5 years age 50 and over)

Colonoscopy: ___________ (recommendations depend on history)

Have you ever had?

_____High blood pressure _____Kidney Disease _____Anemia _____Seizures

_____ Clotting disorders _____Liver Disease _______Diabetes_____Asthma

_____ Heart Disease _____Glaucoma ______ Migraine_____Stroke

_____ Bleeding _____ Ulcers ______ Depression

_____ Drug/Alcohol Abuse _____Nervousness _______Other

Cancer (explain) :_________________________________________________________

Surgeries:_______________________________________________________________

Family History: (any of the above conditions in any family members?)

Father:__________________________________________________________________

Mother:_________________________________________________________________

Siblings:________________________________________________________________

Aunts/Uncles/Grandparents:_________________________________________________

Social History:

Occupation:_____________________________Marital Status:_____________________

Smoking:Packs per day:________Years smoked:______ Years quit:_________________

Do you drink alcohol?_________How much?___________________________________

Do you take or use drugs?______What and how often?___________________________

Female History: First day of last period:______Menopause/Hysterectomy:___________

Last PAP:_____Normal?_______Any Abnormal PAP?_______When?_______________

(Preventative Health:Pelvic exam yearly, PAP 6 mos – 2 yrs depends on age or past PAP)

Last mammogram: ______Normal?_____Any Abnormal?_____When?______________

(Preventative Health: self breast exam monthly. Mammogram every 1-2 yrs 40 and over)

Breast Biopsy:_____Was it cancer?_____ Number of pregnancies:____ Live Births:____

Abortions:_____C-sections:____Vaginal Deliveries:______Hx. of vaginal infections:___

Male History: History of hernia?___Penile infections/discharge/sores?____ Prostate Problems?_______ rectal/prostate exam:____Normal?___ Difficult urinating?_________ (Preventative health: monthly self testicular exams, yearly rectal/prostate exams)