Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)

Source and Reliability of Informant:

Past Use of Health Care System and Health Seeking Behaviors:

Present Health or History of Present Illness:

General Health: (Patient’s own words)

Allergies: (include food and medication allergies)

Reaction:

Current Medications:

Immunizations:

Childhood Illnesses:

Serious or Chronic Illnesses:

Past Accidents or Injuries:

Past Hospitalizations:

Past Operations:

Family History

(Specify which family member is affected.)

Socio-Demographic Content and Questions:

What organizations or activities (community, school, church, lodge, social, professional, academic, sports) are you involved in?

How would you describe your community?

Hobbies, skills, interests, recreational activities?

Military service: Yes_______ No_______

If yes, overseas assignment? Yes________ No_________

Close friends or family members who have died within past 2 years?

Number of relatives or close friends in this area?

Marital status: Single______ Married________Divorced_________Separated_________ In serious relationship________ Length of time_________

Environmental Content and Questions:

Do you live alone? Yes________ No ________

When did you last move?

Describe your living situation?

Number of years of education completed?

Occupation?

If employed, how long?

Are you satisfied with this work situation?

Do you consider your work dangerous or risky?

Is your work stressful?

Over the past 2 years have you felt depressed or hopeless?

Biophysical Content and Questions

Have you smoked cigarettes? Yes_______ No________

How much?

Less than ½ pack per day_____ About 1 pack per day?______ More than 1 and ½ packs per day______

Are you smoking now? Yes_______ No________ Length of time smoking? ______________

Have you ever smoked illicit drugs? Yes__________ No_________

If yes, for how long? ___________ Do you smoke these now? Yes__________ No __________

Do you ingest illicit drugs of any kind? Yes_________ No__________

If so, what drugs do you use and what is the route of ingestion?_________

How long have you used these drugs _________________

Review of Systems

(Include both past and current health problems. Comment on all present issues.)

General Health State (present weight – gain or loss, reason for gain or loss, amount of time for gain or loss; fatigue, malaise, weakness, sweats, night sweats, chills ):

Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion):

Health Promotion (Sun exposure? Skin care products?):

Hair (recent loss or change in texture):

Health Promotion (method of self-care, products used for care):

Nails (change in color, shape, brittleness):

Health Promotion (method of self-care, products used for care):

Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):

Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts):

Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection):

Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):

Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):

Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):

Health Promotion (methods for cleaning nose):

Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste):

Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.):

Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter):

Neurologic System (history of seizure disorder, syncopal episodes, CVA, motor function or coordination disorders/abnormalities, paresthesia, mood change, depression, memory disorder, history of mental health disorders):

Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):

Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):

Health Promotion (last blood glucose test and result, diet):

Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):

Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products):

Respiratory System (History of lung disease, smoking, chest pain with breathing, wheezing, shortness of breath, cough – productive or nonproductive. Sputum – color and amount. Hemoptysis, toxin or pollution exposure.):

Health Promotion (last chest x-ray, smoking cessation):

Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):

Health Promotion (last cardiac exam):

Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or ulcers):

Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support hose):

Hematologic System (bleeding tendency of skin or mucous membranes, excessive bruising, swelling of lymph nodes, blood transfusion and any reactions, exposure to toxic agents or radiation):

Health Promotion (use of standard precautions when exposed to blood/body fluids):

Gastrointestinal System (appetite, food intolerance, dysphagia, heartburn, indigestion, pain [with eating or other], pyrosis, nausea, vomiting, history of abdominal disease, gastric ulcers, flatulence, bowel movement frequency, change in stool [color, consistency], diarrhea, constipation, hemorrhoids, rectal bleeding):

Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives):

Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):

Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion):

Urinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence; history of urinary disease; pain in flank, groin, suprapubic region or low back):

Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel exercises):

Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia):

Health Promotion (performs testicular self-exam):

Female Genital System (menstrual history, age of first menses, last menstrual cycle, frequency of cycles, premenstrual pain, vaginal itching, discharge, premenopausal symptoms, age at menopause, postmenopausal bleeding):

Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products):

Sexual Health (presently involved in relationship involving intercourse or other sexual activity, aspects of sex satisfactory, use of contraceptive, is relationship monogamous, history of STD):

Health Promotion (safe-sex practices):