Social History. Include pertinent findings about use of tobacco products, alcohol, prescription and non-prescription drugs, etc.;
Social History. Smoking Status: Never Smoker□ Former Smoker□ Cigar Smoker□ Current Every day Smoker□ Start Date: Do you drink alcohol? Quit Date: Number of packs per day: Total years Smoking: Yes No If yes, drinks/day How many times in the past year have you had 4 or more drinks in the same day? Are you pregnant? Yes No If yes, how many weeks? Recreational drugs? Yes No If yes, what drugs? Immunization: Have you had your Influenza Vaccine this year or last year? Yes□ No□ Declined□ If yes, when? Have you had your Pneumonia Vaccine with in the past 5 years? Yes□ No□ Declined□ If yes, when? Any other vaccinations this year? Yes□ No□ What is your occupation? May we leave a detailed message on your phone? Yes No Phone: Pharmacy Information Name: Address if known: Phone: City: Pediatric History (only for minors) Gestational age at birth (in weeks): weeks Birth Weight: lbs oz Maternal illness during pregnancy: Completed by Patient: Signed by patient or responsible party Date:
Social History. What is your current living situation (who lives with you? Please include names and ages of children/parents): Are you experiencing any legal problems (problems types including DUI's, probation officer involvement, pending court dates, arrests, jail time): What do you do for work? What is your satisfaction level with your occupation? Please specify your level of education: What groups, religious affiliations, and supportive networks are you a part of? Please specify those of primary importance: Alcohol & Substance Use Alcohol Use: Yes / No If yes, how much/ how often: Are you currently able to abstain for 72 hours? Nicotine Use: Yes / No If yes, how much/ how often: Are you currently able to abstain for 72 hours? Caffeine Use: Yes / No If yes, how much/ how often: Are you currently able to abstain for 72 hours? Marijuana Use: Yes / No If yes, how much/ how often/how are you ingesting: Are you currently able to abstain for 72 hours?
Social History. How would you describe your support system in the area? • What does a typical day look like for you? What do you enjoy doing? • Do you identify with any religious background or spiritual practice? • Children: ☐ Yes ☐ No Are you a new or expecting parent? ☐ Yes ☐ No Notes on children (i.e. custody, # of dependent children): • Have you had significant periods in which you have had experienced serious problems getting along with people in your life? Note: “Serious problem” means those that endangered the relationship. Also, a “problem” requires contact of some sort, either by telephone or in person In the past 30 days In the past year No Yes No Yes Parents (mother or father) ☐ ☐ ☐ ☐ Siblings ☐ ☐ ☐ ☐ Sexual partner/spouse ☐ ☐ ☐ ☐ Children ☐ ☐ ☐ ☐ Other significant family (specify) ☐ ☐ ☐ ☐ Close friends ☐ ☐ ☐ ☐ Neighbors ☐ ☐ ☐ ☐ Co-workers ☐ ☐ ☐ ☐ Health & Wellbeing • Do you have a primary care physician? If so, who and when did you last see them? _ • When was the last time you saw a doctor/nurse? What was the purpose? How was the experience? • • Number of ER visits in the last year: • Hospital inpatient days in the last year: • Hospital admissions in the last year: • Notes: • Have you ever been a victim of a violent attack during homelessness? ☐ Y ☐ N • Have you ever had any serious head injury/trauma? (Did you lose consciousness? Were you hospitalized? Was surgery required?) _ • Do you currently have any pain or discomfort? Is it chronic or sporadic? • Are you prescribed any medications? ☐ Y ☐ N NAME: DOSE: PURPOSE: DURATION: PRESCRIBER: • Have you been prescribed medications while in jail/prison? ☐ Y ☐ N • How is your sleep? How many hours per day/night? • Do you have vision or dental concerns? • Do you have any of the following ongoing health issues and are you receiving care for this issue? Health issues Have this issue? If yes, receiving care? No Yes No Yes Kidney disease or dialysis ☐ ☐ ☐ ☐ Liver disease or cirrhosis ☐ ☐ ☐ ☐ Heart disease or history of heart attack ☐ ☐ ☐ ☐ HIV+/AIDS ☐ ☐ ☐ ☐ Emphysema ☐ ☐ ☐ ☐ Diabetes ☐ ☐ ☐ ☐ Asthma ☐ ☐ ☐ ☐ Cancer ☐ ☐ ☐ ☐ Hepatitis C ☐ ☐ ☐ ☐ Tuberculosis ☐ ☐ ☐ ☐ Seizure disorder ☐ ☐ ☐ ☐ Stroke ☐ ☐ ☐ ☐ Other ☐ ☐ ☐ ☐ Other ☐ ☐ ☐ ☐ • Do you have any concerns about your mental health? (Onset? When did you first receive tx? Previous diagnoses? Most recent diagnosis?) _ _ • Has anyone ever told you that you have mental illness? _ _ • Overall, how would you describe your mood? _ _ • Have you ever been prescribed medication for m...
Social History. Do you currently smoke cigarettes? ❑ Yes ❑ No How many packs a day? _ ❑ Never smoked Age started? Have you quit smoking cigarettes? When? How many packs a day? _ _ (Congratulations !) Age started? _ Age stopped? Have you chewed tobacco? ❑ Yes ❑ No How many cans per day?_ ❑ Never Age started? _ ❑ Former Age stopped? ❑ Current Do you drink alcoholic beverages? ❑ Former ❑ Yes ❑ No Average drinks per week Have you used “street” drugs? ❑ Yes ❑ No Type Quantity: Age started: _ Age stopped: Have you ever taken steroids? ❑ Yes ❑ No When? _ Reason Family History: ❒ None Medical problems of parents/brothers/sisters, such as cancer, heart disease, arthritis, high blood pressure, diabetes, bleeding problems, trouble with anesthesia, alzheimers, stroke, mental illness:
Social History. Include pertinent findings about use of tobacco products, alcohol, prescription/non-prescription drugs, etc. Comment on the effects of substance abuse on functioning. If there is no history of substance abuse, include a statement to that effect; and iv. Family History (if pertinent). (e) Review of Systems. Review all body systems. Describe any specific complaints and discuss:
Social History. Do you smoke: How many packs per day? How many years? When did you quit? Do you drink alcohol? FAMILY MEDICAL HISTORY How many drinks per week? ☐yes☐no Family hx of prostate cancer? When did you quit? Do you use any illicit drugs? - Review of Systems- Yes No Constitutional Yes No Psychiatric ☐ ☐ Unwanted weight loss ☐ ☐ Depression ☐ ☐ Fever (last 72 hours) ☐ ☐ Anxiety ☐ ☐ Chills (last 72 hours) ☐ ☐ Suicidal ideation Yes No HEENT Yes No Genitourinary ☐ ☐ Change in vision ☐ ☐ Pain while urinating ☐ ☐ Problems swallowing ☐ ☐ Burning while urinating ☐ ☐ Yes No Glaucoma Cardiovascular ☐ ☐ Blood in urine ☐ ☐ Hesitancy in going ☐ ☐ Incontinence ☐ ☐ History of blood clots ☐ ☐ Retention of urine ☐ ☐ Chest pain (last 72 hours) ☐ ☐ Difficulty with erections ☐ ☐ Palpitations (last 72 hours) ☐ ☐ Pain with intercourse ☐ ☐ Dizziness (last 72 hours) ☐ ☐ Weak urinary stream ☐ ☐ Strain to urinate Yes No Endocrine ☐ ☐ Bladder/kidney infections ☐ ☐ Excessive thirst ☐ ☐ Heat/cold intolerance ☐ ☐ Hot Flashes Yes No Respiratory ☐ ☐ Frequent cough ☐ ☐ Short of breath (last 72 hours) ☐ ☐ Wheezing (last 72 hours) ☐ ☐ Frequency of urination Yes No Musculoskeletal ☐ ☐ Joint pain ☐ ☐ Neck pain ☐ ☐ Back pain Yes No Neurological ☐ ☐ Strokes Yes No Gastrointestinal ☐ ☐ Seizures ☐ ☐ Nausea ☐ Tremors ☐ ☐ Vomiting ☐ ☐ Rectal bleeding Yes No Skin ☐ ☐ Rashes ☐ ☐ Jaundice ☐ ☐ Boils ☐ Height: (ft) (in) Weight: (lbs) MALE AMERICAN UROLOGICAL ASSOCIATION (AUA) SYMPTOM SCORE Have you noticed any of the following when you have gone to the bathroom to urinate over the past month? Circle the correct answer for you and write your score in the right hand column. Talk with a health care provider if your total score on the first seven questions is 8 or greater or if you are bothered at all. Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Your Score
Social History. Please list family members and significant others: Name Relationship Age Name Relationship Age What is the nature of the relationship with your: Mother: Father: Siblings: Peers: Significant Others: How do you think the following people would describe their relationship with you: Mother:
Social History. If YES, amount & type: If YES, how often: If YES, type & amount: If YES, type, age, by whom: ____________________________________ ____________________________________ ____________________________________ ____________________________________ Family Medical History (Please include any medical illnesses and cause of death) Father: ____________________________________________________________________________ Mother: ____________________________________________________________________________ Siblings: ____________________________________________________________________________ Others: ____________________________________________________________________________ Medications (please include “over the counter meds” as well) Name: Strength: How Often: PATIENT REGISTRATION FORM (Please Print) xxx.xxxxxxxxxxxxxxx.xxx 0000 Xxxxxxxx Xxxxxxx Suite 307 Today's Date: / / Primary Care Doctor: Frisco, Texas 75033 PATIENT INFORMATION Legal First Name Legal Last Name Suffix Gender Address Apt # City State Zip ( ) ( ) - - Primary Phone Cell Phone Social Security # / / Birth Date ¢Married ¢Single ¢Divorced ¢Widowed ¢Other ¢ Email Address (this will be used for appointment reminders and newsletters) Preferred Contact Method ¢Cell ¢Home ¢Email Check for portal access Race Ethnicity Preferred Language ( ) Employeer Name Employeer Phone Number
Social History l. Xxxxx Xxxxx
