Review of Systems. Eye/Ear/Nose/Throat. hard to empty bladder. palpitations/irregular heartbeat. persistent cough, wheezing. feelings of depression

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Name: ____________________________ DOB: ____/ ____ / ____

For staff: place patient label here.

Review of Systems

Check here if no symptoms.

Check concerns below only if you have experienced symptoms recently.

General

Urologic

loss of appetite

frequent urination

abnormal weight gain

painful urination

abnormal weight loss

blood in urine

night sweats

bladder leakage

fatigue

hard to empty bladder

Eye/Ear/Nose/Throat

Genital

Vision changes

abnl menstrual bleeding

Ringing in ears

painful periods

difficulty hearing

sexual difficulty

nasal congestion

breast lump/discharge

difficulty swallowing

vaginal/penile discharge

Cardiovascular

Neurological

chest pain

headache

palpitations/irregular heartbeat

dizziness

fainting/blackouts

localized weakness

leg swelling

memory loss

Respiratory

Musculoskeletal

persistent cough, wheezing

back pain

shortness of breath

joint pain

coughing up blood

frequent falls

Gastrointestinal

Psychiatric

reflux

feelings of depression

abdominal pain

apathy/disinterest

chronic constipation

nervous/anxious

chronic diarrhea

irritable

nausea/vomiting

sleeping problems

blood in stool

excessive thirst

Hematologic/Skin

Endocrinologic

abnormal bleeding/bruising

heat/cold intolerance

mole changes

excessive sweating

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Name: ____________________________ DOB: ____/ ____ / ____

For staff: place patient label here.

ADC Family Practice New Adult Patient/Annual Form

Reason for your visit

__________________________________________________

Past Medical History:

Please review the below list, and check any problems that you have had now or in the past.

Abnormal Pap Smear Drug Abuse Osteoarthritis

Acne Emphysema Osteopenia

Adult ADD Eczema Osteoporosis

Alcohol abuse Frequent Urinary Tract Infection Positive TB skin test Anemia Frequent Sinus Infections Prostate problems

Anorexia Gallstones Psoriasis

Anxiety disorder Gout Reflux (heartburn)

Asthma Glaucoma Rheumatoid Arthritis

Atrial Fibrillation Heart Attack Rosacea

Bipolar disorder Heart Disease Seasonal Allergies

Blood clot Hepatitis Seizures

Blood Transfusion High Blood Pressure Sexually transmitted disease

Breast Cancer High cholesterol Which One:

Chronic Bronchitis Irritable Bowel Syndrome Stroke

Crohn’s disease Kidney Stones Tuberculosis

Colon Polyps Kidney disease Thyroid disease/cancer

Congestive Heart Failure Kidney Infections Stomach Ulcers

Depression Lupus Ulcerative Colitis

Diabetes Melanoma or other skin Cancer Valve problem/murmur

Diverticulosis Migraines Other

Current Medications:

Please include over-the-counter medications and food supplements

Drug Name: Dose: How Often? Drug Name: Dose: How Often?

Are You Allergic to any medications? Yes No

Drug Name: Type of Reaction Drug Name: Type of Reaction

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Reproductive History:

1. Are you sexually active: Yes No

2. Number of sexual partners: _______ (in the past year) _______ (in the last 5 years) 3. Sexual preference (check one): male female both

4. Type of birth control (check all that apply): pills patch ring implant under skin spermacide Depoprovera IUD tubal ligation vasectomy natural family planning condoms

For women only:

1st day of last menstrual period # of pregnancies

Age of first period # of live births

Age of menopause # of miscarriages

Last abnormal pap (year) # of abortions

If you had an abnormal pap did you have a colposcopy? Yes No Did you have treatment (cryo, laser, LEEP, cone biopsy)? Yes No

Surgical History:

Have you had surgery in the past? Yes No If yes, please check or list:

Type of surgery: Year Type of surgery: Year

Appendectomy Hysterectomy

Arthroscopy (Joint) Knee Replacement

Back Surgery LEEP/LOOP (cervix)

Bypass surgery (Heart) Mastectomy/lumpectomy

Cataract Surgery Neck surgery

Cesarean section Polyp removal

Gallbladder removal Tonsillectomy

Hemorrhoids Vasectomy/Tubal ligation

Hernia Plastic Surgery

Hip Replacement Other:

Any hospitalizations (other than births and surgeries)? Yes No If yes, please explain: ______________ _________________________________________________________________________________________

Family History:

(grandparents, brothers, sisters, parents, aunts, uncles, children) Have any of your family members had any of the following problems?

Condition Family member

and age of onset? Condition Family member

Breast Cancer Depression/Anxiety

Colon Cancer Other mental issues

Prostate Cancer Alcohol/drug problems

Ovarian Cancer High cholesterol

Melanoma Blood clotting disorder

Heart Disease/Attack Osteoporosis

Stroke Rheumatoid Arthritis

Diabetes Lupus

High Blood Pressure Ulcerative Colitis

Thyroid Disease Crohn’s Colitis

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Social History:

Social System:

Marital status (check one): single divorced separated married widowed

Number of children (include names and ages): _____________________________ List all household members _____________________________________________ Highest level of education reached ______________________________________

Occupation ________________________________________________________ Yes No 1. Do you have adequate family or community support?

Yes No 2. Do you have any concerns for your safety (emotional, physical, sexual abuse)?

Nutrition & Exercise

Yes No 1. Do you follow a specific diet (vegetarian, vegan, gluten-free)? ____________

2. How many servings of dairy or calcium rich foods do you eat per day _________

Yes No 3. Do you take a calcium supplement? Yes No 4. Do you take a multi-vitamin?

Yes No 5. Do you skip meals often?

6. How many meals per week are take-out/dine-out? ______________________

Yes No 7. Do you exercise?

If so, what type ____________________ and how often? ___________________

Yes No 8. Would you like more information on weight loss strategies?

Healthy Habits

Smoking history: Never Current Past (Quit date ________ )

1. What type? Cigarettes E-cigarettes Cigars Pipes Chewing tobacco 2. How much do/did you smoke (#/day)? ______________/__________________ 3. How many years have you smoked in total? _____________________

Yes No 4. Are you interested in quitting? Yes No 5. Any smoker in your household?

Yes No 6. Do you drink caffeine? If so, how much? ___________________ Yes No 7. Have you ever used street drugs?

8. Which ones? IV marijuana amphetamines cocaine heroin downers inhalants

Yes No 9. Are you still using? Which ones? ____________________________ Yes No 10. Do you drink alcohol? Drink of choice? _________________________

If so, how many times? ___per week OR _____ per month OR _____ per year How many drinks at one time? ____________________

Yes No 11. Have you ever had a problem with alcohol (legal, financial, social, personal or work related)? If yes, please explain?____________________________________

Yes No 12. Do you wear a seat belt? Yes No 13. Do you wear a helmet? Yes No 14. Do you wear sunscreen?

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Health Maintenance:

Have you ever had the following:

Cholesterol screening? Yes No Results: ___________________________________ Diabetes screening? Yes No Results:____________________________________ Prostate screening (PSA)? Yes No Results:____________________________________ Pneumonia Vaccine? Yes No When? ____________________________________ Flu shot? Yes No When? ____________________________________

Tetanus/Pertussis shot? Yes No What year? ________________________________ Hepatitis B Vaccine? Yes No Did you complete the series? Yes No

Human Papilloma (Gardasil) Vaccine? Yes No Did you complete the series? Yes No Shingles Vaccine? Yes No When? __________________________

Colon Cancer screen? Yes No (colonoscopy, flexible sigmoidoscopy)

What year? _________ Results? __________________________________________________

Bone Density? Yes No Date: ___/____/____ Results: ____________

Mammogram? Yes No Date: ___/____/____ Results: ____________

Figure

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