Ruth Haskins, MD, Inc.

 

INITIAL HEALTH HISTORY

Welcome to our practice!  In order to provide you with the best, most comprehensive care possible, we request that you provide the following information.  All information is held in strictest confidence, and is only released with your written permission.

Name:  _____________________________ DOB:  _________________   Today’s Date:  __________________

Chronic Medical Conditions:  __________________________________________________________________

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Past Surgeries (list year surgery was performed):  Ex- wisdom teeth extracted (1996), back surgery (2005)

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Medications (all remedies currently using):______________________________________________________

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Allergies:

Allergies to Drugs (list reaction):  Ex-penicillin (full body hives), Iodine (rash)

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Latex Allergy?  _____ Yes      _____ No

Past Medical Conditions (not including chronic conditions listed above):

Ex- hospitalized for gall stones (2003 & 2007), Migraines (2009-2010)

Childhood Illnesses:  ___________________________________________________________________

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Adult Illnesses:  _______________________________________________________________________

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 Social History & Habits: 

Occupation: _________________________________________________________________________

Exercise:       _____ None          _____ Occasional           _____ Moderate         _____ Extreme

Exercise Method: _____________________________________________________________________

Diet:         _____ normal           _______ Vegetarian            _____ Vegan                       _____ Gluten Free

            Limitations or restrictions:  _______________________________________________________

Relationship Status: _____ Single ­­_____ Married _____ Separated _____ Divorced _____ Widowed

                                  _____ Domestic Partner _____ other: ____________________________________

Smoker: _____ Never Have _____ Quit _____ Over Pack/Day _____ Under Pack/Day _____ Occasional      

Alcohol:        _____ None           _____Social         _____ Moderate         _____ Problem

Illicit Drugs: _____ Never               _____ Remote                    _____ Current ________________________

            Have you ever been sexually active? _____ Yes _____ No

Are you currently sexually active? _____ Yes _____ No

Total number of sexual partners in your lifetime: _____ Over five        _____ Under five

History of Abuse (physical or sexual): _____ Yes _____ No

Do you have an Advanced Directive: _____ Yes _____ No

If I needed a transfusion of blood to save my life, I would accept it: _____ Yes _____ No

 

Serious Family History (list age of onset and age of death, if applicable):

Ex- maternal grandmother: colon cancer, onset 65 still living, mother: type II diabetes, onset ? still living

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Gynecologic History:

Age of First Period: ______________________    1st day most recent Menses _____________________

How often do you get your period? _______________________________________________________

How long does your typical period last? __________________________________________________

Flow:       _____Light       _____ Moderate      _____ Heavy

Problems with your period: _____________________________________________________________

Current Birth Control Method: ___________________________________________________________

Age became menopausal (if applicable):  ___________

Use of Hormone Therapy: ______________________________________________________________

Problems with Menopause: _____________________________________________________________

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Obstetric History:

Pregnancies:      _____ Total Number      _____ Deliveries        _____ Miscarriages           _____ Abortions

Complications: _______________________________________________________________________

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Other doctors currently caring for you: _________________________________________________________

Your Favorite Pharmacy: ____________________________________________________________________

 

Problems Of Concern to You Today:

 

 

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