Name:DOB:

PatientHistory

ThankYouforchoosingRoperSt.FrancisPhysiciansPartners–PrimaryCare.Welookforwardtodevelopingarelationshipwithyouandcollaboratingonyourhealthcare.Inordertobetterserveyou,pleaseprovideuswithyourmedicalhistory.

PreventiveHealthImmunization DatePerformedAnnualLab(Inthepastyear)InfluenzaVaccinationPrevnar(1stPneumoniashot)Pneumovax(2ndPneumoniashot)TetanusVaccinationTDAP(Whoopingcough)Zostavax(Shinglesvaccine)Shingrix(Shinglesvaccine)ScreeningTest DatePerformed Results(Normal/Abnormal) LocationColonoscopy/ColonScreeningMammogramPAP(cervicalcancerscreen)PSA(Prostate)/DRE(rectalexam)ChestX-RayChestCT(LungScan)DexaScan(BoneScan)EyeExamOther:

MedicationsPleaselistallmedicationsyouaretakingcurrently,includingoverthecounterandherbalremedies.Pleaseincludedosageandnumberoftimesadaythemedicationistakenifknown.

MedicationName: Dosage(mg,cc,etc) Frequency(howoften)

PastMedicalHistoryPleasemarkanycurrentorpreviousillnessesorhealthproblems.

ADD/ADHD Dementia KidneyStones

Name: DOB:

PatientHistory Anxiety Depression Lupus Anemia DegenerativeJointDisease LungProblems Arthritis DiabetesMellitus MaleProblems AsbestosExposure Drug/AlcoholAddiction Parkinson’sDisease Asthma FemaleProblems RheumatoidArthritis BipolarDisorder HeartAttack SeizureDisorder BleedingDisorder HeartDisease Schizophrenia BloodClots HeartRhythmProblem Stroke Cancer(type)_______________ Hepatitis SickleCell COPD/Emphysema HighCholesterol ThyroidDisease ChronicPainrelated HighBloodPressure Tuberculosis(positivePPD) to____________________ HIV/AIDS Ulcers KidneyDisease OtherHistory/Details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________AllergiesPleaselistallfoodanddrugallergies: SurgicalHistory/MajorDiagnosticProcedures Appendectomy GallBladder Hysterectomy BackSurgery LungBiopsy (wascancerinvolved____) Bariatric(WeightReduction) LungResection Tonsillectomy Breast HeartCatheterization TubalLigation (wascancerinvolved____) HeartBypassSurgery TumorRemoval C-Section ProstateSurgery VasectomyOtherHistory/Details___________________________________________________________________________-_________________________________________________________________________________________________________________________________________________________________________________Hospitalizations/EmergencyRoomVisitsReason Date SocialHistoryHaveyoueversmoked?(cigarettes,vape,cigars,etc.)___No ___YesHowmanyperday?____________Howmanyyears?______________Stopdate_______________Doyoudrinkalcohol?___No ___YesHowmanydrinksperweek?______________________

Name: DOB:

PatientHistoryDoyouuseanystreetdrugs?___No___YesIfyespleaselist________________________

FemalePatientsNumberofPregnancies? Numberoffullterm(>38wks)births? Numberofprematurebirths? Numberofmiscarriagesorabortions? Numberoflivingchildren?

FamilyHistoryAreyouadopted? Yes No Father Mother Siblings PaternalGF PaternalGM MaternalGF MaternalGMLiving Deceased Diabetes Hypertension HeartDisease MentalIllness Cancer(type) Stroke ThyroidDisease HighCholesterol BloodClots LungDisease Tuberculosis MentalIllness Headaches Seizure COPD/Emphysema Other(specify) Unknown