DUKE PRIMARY CARE HEALTH HISTORY Name: ________________________________________ Sex Male Female Date__________________ Date of Birth ____/____/____Marital Status:

: Married Single Separated Divorced Widowed Do you have any health concerns? If yes, please list PAST MEDICAL HISTORY: Check conditions that doctors have followed you for in the past: High blood pressure/hypertension High Cholesterol Liver Disease Diabetes (sugar) Thyroid Problems Kidney Disease Heart Attack/By-pass Surgery Heart Failure Heart Murmur Mitral Valve Prolapse Stroke Seizures/Epilepsy Stomach Problems Intestinal Problems Reflux Disease Glaucoma Psychiatric Illness Arthritis Abnormal PAP Cancer: Type & Location __________________________________________________________________ Other:___________________________________________________________________________________ Have you ever had: Positive Tuberculosis Test Yes No Rheumatic Fever Yes No Blood Transfusion Yes No List any hospitalizations or surgeries you have had (including C-section): __________________________________________________________________________________________ __________________________________________________________________________________________ List any drug allergies: __________________________________________________________________________________________ Are you allergic to latex? Yes No

List all current medications (including vitamins, herbal, and health food preparations) : _____________________________ _____________________________ ___________________________ _____________________________ _____________________________ ____________________________ _____________________________ _____________________________ ____________________________ PREVENTATIVE CARE: When was your last: Tetanus Booster __________ Flu Shot ________ Pneumonia Vaccine _________Hepatitis Vaccine________ Flexible Sigmoidoscopy/Colonoscopy _____________________________ Bone Densitometry___________

Female Only: How often do you examine your breasts? ___________ Do you see an OB?GYN doctor?______ When was your last mammogram?____________________ When was your last PAP smear?_______________ Male Only: Do you do a testicular exam? _________ Do you have any problems with erections? ____________ When was your last: prostate blood test (PSA) ____________ Prostate/rectal exam? _____________________ PLEASE COMPLETE BACK OF FORM

SOCIAL HABITS

Have you ever used tobacco products? Yes No What kind? ______________________________ How much? ______________________________ For how many years? ______________________ Date quit?________________________________

Do you drink alcohol? Yes No How many drinks per week? _______ Have you ever felt you need to cut down? Yes No Have you ever felt guilty about our drinking? Yes No Do you use drugs? Yes No What type?___________ How often?______________________________________ How many glasses/cups of caffeine do you drink daily? __________ Do you have guns in your home? ______ Do you exercise outside of your job?______Do you wear seatbelts? always usually sometimes never What is your occupation? _________________________Who do you live with?_________________________ How do you learn best? Read it Tell me Show me How much education have you completed? ________ Are you: sexually active If so, 1 partner multiple partners with women with men A parent If so, how many children? _____________________
FAMILY HISTORY: Has anyone in your family had any of the following? (Check appropriate box) Mother Father Maternal Paternal Brothers/ Other Grandparent Grandparent Sisters High Blood Pressures/ Hypertension Heart Attack/ Heart Surgery Diabetes Stroke Cancer (Type/Location) Osteoporosis Thyroid Problems Mental Illness Glaucoma Please check any of the following problems that apply to you: General Genitourinary Skin ____ no problems Allergy Eyes

Endocrine System

fever sweats
Respiratory

cough shortness of
breath

urinary frequency burning with urination blood in urine problems urinating awaken at night to
urinate

rash changing mole itching slow healing

wounds Cardiovascular

excessive urination excessive thirst fatigue heat intolerance cold intolerance

Neurologic System

wheezing problems with sex shortness of exposure to sexually

breath with exertion transmitted disease Mental Health

chest pain or
pressure

ankle swelling palpitations

Daily Living

numbness tingling headaches weakness

seasonal symptoms blurred vision sneezing changing vision itchy eyes runny nose GI System nasal congestion nausea post nasal drip vomiting Hematologic System constipation easy bruising abdominal pain easy bleeding diarrhea hard to stop blood in stool
bleeding Musculoskeletal Nutrition

insomnia Ear/Nose/Throat guilt ear pain depression runny nose anxiety sneezing suicidal thoughts post nasal drip
swelling

violence in your home changes in functional ability changes in eating habits changes in sleeping habits

joint swelling joint pains muscle pains

On a special diet weight gain or

loss greater than 10 pounds