RUA: Health History paper

HealthhistoryquestionnairePATIENT.docx

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	Dates Revised:	enter text.
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HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Initials: N/A	Race/Ethnicity: Caucasian/White	☐M ☒ F	Age 20s	Occupation: Student Nurse
Marital status:	☒ Single ☐ Partnered ☐ Married ☐ Separated ☐ Divorced ☐ Widowed
Reason for visit: Annual check-up	Perception of health:”I’m just here for a yearly check-up”	Date of last physical exam:	6/11/2020
Source of information: Patient		Reason for seeking care: yearly check-up
Present health or history of present illness:
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Q	enter text.
R	enter text.
S	enter text.
T	enter text.

PERSONAL HEALTH HISTORY/Past health

Childhood illness:	Measles Mumps Rubella Chickenpox Rheumatic Fever Polio
Immunizations and dates:	☒Tetanus	June 2016	☐Pneumonia	N/A
	☒Hepatitis	August 2020	☒Chickenpox	June 2000
	☒Influenza	August 2020	☒MMR Measles, Mumps, Rubella	August 2020
List any medical problems that other doctors have diagnosed
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Surgeries
Year	Reason	Hospital
N/A	N/A	N/A
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Other hospitalizations
Year	Reason	Hospital
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Have you ever had a blood transfusion?	☐	Yes	☒	No
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List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Name the Drug	Strength	Frequency Taken and Reason
Cryselle	N/A	Every day; Birth Control
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Allergies to medications, latex, food, iodine/betadine
Name the Drug	Reaction You Had
NSAIDS	Nose bleed
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HEALTH HABITS AND PERSONAL SAFETY

All questions contained in this questionnaire are optional and will be kept strictly confidential.
Exercise	☐Sedentary (No exercise)
	☐Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
	☒Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
	☐Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Diet	Are you dieting?	☐	Yes	☒	No
	If yes, are you on a physician prescribed medical diet?	☐	Yes	☒	No
	# of meals you eat in an average day? 2 meals
	Rank salt intake	☒Hi	☐Med	enter text.Low
	Rank fat intake	☐Hi	☐Med	X Low
Caffeine	None	☒Coffee	☐Tea	enter text.Cola
	# of cups/cans per day? ☒
Alcohol	Do you drink alcohol?	☐	Yes	☒	No
	If yes, what kind? enter text.
	How many drinks per week? enter text.
	Are you concerned about the amount you drink?	☐	Yes	☒	No
	Have you considered stopping?	☐	Yes	☒	No
	Have you ever experienced blackouts?	☐	Yes	☒	No
	Are you prone to “binge” drinking?	☐	Yes	☒	No
	Do you drive after drinking?	☐	Yes	☒	No
Tobacco	Do you use tobacco?	☐	Yes	☒	No
	☐Cigarettes – pks./day N/A	☐Chew - #/day N/A	☐Pipe - #/day N/A	☐Cigars - #/day N/A
	☐ # of years N/A	☐Or year quit N/A
Drugs	Do you currently use recreational or street drugs?	☐	Yes	☒	No
	Have you ever given yourself street drugs with a needle?	☐	Yes	☒	No
Sex	Are you sexually active?	☒	Yes	☐	No
	If yes, are you trying for a pregnancy?	☐	Yes	☒	No
	If not trying for a pregnancy list contraceptive or barrier method used: Oral Contraceptives
	Any discomfort with intercourse?	☐	Yes	☒	No
	Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?
		☐	Yes	☒	No
Personal Safety	Do you live alone?	☐	Yes	☒	No
	Do you have frequent falls?	☐	Yes	☒	No
	Do you have vision or hearing loss?	☐	Yes	☒	No
	Do you have an Advance Directive and/or Living Will?	☐	Yes	☒	No
	Would you like information on the preparation of these?	☒	Yes	☐	No
	Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?
		☐	Yes	☒	No

FAMILY HEALTH HISTORY

	Age	Significant Health Problems		Age	Significant Health Problems
Father	40s	N/A	Children	☐M ☐ F		enter text.
Mother	40s	N/A		☐M ☐ F		enter text.
Sibling	☐M ☒ F		N/A		☐M ☐ F		enter text.
	☐M ☒ F		N/A		☐M ☐ F		enter text.
	☐M ☒ F		N/A	Grandmother Maternal	70s	N/A
	☒M ☐ F		N/A	Grandfather Maternal	70s	COPD, CHF
	☐ M ☐ F		enter text.	Grandmother Paternal	70s	N/A
	☐M ☐ F		enter text.	Grandfather Paternal	60s	N/A

MENTAL HEALTH	Comments

Is stress a major problem for you?	☒	Yes	☐	No
Do you feel depressed?	☐	Yes	☒	No
Do you panic when stressed?	☒	Yes	☐	No
Do you have problems with eating or your appetite?	☐	Yes	☒	No
Do you cry frequently?	☐	Yes	☒	No
Have you ever attempted suicide?	☐	Yes	☒	No
Have you ever seriously thought about hurting yourself?	☐	Yes	☒	No
Do you have trouble sleeping?	☐	Yes	☒	No
Have you ever been to a counselor?	☐	Yes	☒	No

WOMEN ONLY

Age at onset of menstruation: 12 years
Date of last menstruation: 12-17-2020
Period every month for abt 5 days
Heavy periods, irregularity, spotting, pain, or discharge?	☒	Yes	☐	No
Number of pregnancies N/A Number of live births N/A
Are you pregnant or breastfeeding?	☐	Yes	☒	No
Have you had a D&C, hysterectomy, or Cesarean?	☐	Yes	☒	No
Any urinary tract, bladder, or kidney infections within the last year?	☐	Yes	☒	No
Any blood in your urine?	☐	Yes	☒	No
Any problems with control of urination?	☐	Yes	☒	No
Any hot flashes or sweating at night?	☐	Yes	☒	No
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?	☐	Yes	☒	No
Experienced any recent breast tenderness, lumps, or nipple discharge?	☐	Yes	☒	No
Date of last pap and rectal exam? 10/2020

MEN ONLY

Do you usually get up to urinate during the night?	☐	Yes	☐	No
If yes, # of times enter text.
Do you feel pain or burning with urination?	☐	Yes	☐	No
Any blood in your urine?	☐	Yes	☐	No
Do you feel burning discharge from penis?	☐	Yes	☐	No
Has the force of your urination decreased?	☐	Yes	☐	No
Have you had any kidney, bladder, or prostate infections within the last 12 months?	☐	Yes	☐	No
Do you have any problems emptying your bladder completely?	☐	Yes	☐	No
Any difficulty with erection or ejaculation?	☐	Yes	☐	No
Any testicle pain or swelling?	☐	Yes	☐	No
Date of last prostate and rectal exam? enter text.

review of systems

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.

☐	Skin/Hair/Nails N/A	☐	Respiratory N/A	☐	Neurologic N/A
☐	Head/Neck N/A	☐	Cardiovascular N/A	☐	Recent changes in Weight N/A
☒	Eyes Stigmatism in left eye	☐	Peripheral Vascular N/A	☐	Recent changes in Energy level Normal
☐	Ears N/A	☐	Gastrointestinal N/A	☐	Sleep/rest pattern N/A
☐	Nose N/A	☐	Urinary N/A	☐	Other pain/discomfort: N/A
☐	Mouth/Throat N/A	☐	Musculoskeletal N/A

RUA: Health History paper

Original Date:

Dates Revised:

HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Age 20s

Marital status:

Reason for visit: Annual check-up

Date of last physical exam:

Source of information: Patient

Reason for seeking care: yearly check-up

PERSONAL HEALTH HISTORY/Past health

Childhood illness:

Immunizations and dates:

List any medical problems that other doctors have diagnosed

Surgeries

Other hospitalizations

Have you ever had a blood transfusion?

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Allergies to medications, latex, food, iodine/betadine

HEALTH HABITS AND PERSONAL SAFETY

Exercise

Diet

Caffeine

Alcohol

Tobacco

Drugs

Sex

Personal Safety

FAMILY HEALTH HISTORY

Father

Children

Mother

Sibling

Grandmother

Grandfather

Grandmother

Grandfather

MENTAL HEALTH

Comments

WOMEN ONLY

MEN ONLY

review of systems