Medical  Intake Information

Please feel free to take your time and carefully fill out the following form. This form must be filled out by all patients before treatment begins.

Name:

Date:

Occupation:

Past Illnesses

Please check any illnesses you have had.

      Asthma

      Hay Fever

 Emphysema

     TB

      Kidney Trouble

     High Blood Pressure

      Heart Trouble

      High Cholesterol

      Rheumatic Fever

      Diabetes

      Stroke

      Cancer

       (type)

      Anemia

      Arthritis

      Gout

      Abnormal Pap Smear

      Stomach Ulcer

      Mental Illness

      Seizures

     Depression

      Back Trouble

      Bowel Trouble

      Thyroid Disease

      Glaucoma

      Gallstones

      Hepatitis

      Liver Problems

      Bleeding Problems

      Skin Problems

      Alcohol Problem

      Drug Addiction

      Hearing Loss

      Polyps of Bowel

      Sexually Transmitted Disease (VD)    

Other

Immunizations

Please check any immunizations you have had and write down the year.

     Rubella

     Measles

      Tetanus

     Pneumovax

     Hepatitis B

Allergies

Please check any allergies that you have and write any reactions in the space provided.

      Penicillin

      Sulfa

      Aspirin

     Codeine

      Bee Stings

      Foods

Surgery

Please check any surgery you have had.

      Appendix

      Tonsils

      Hernia

     Gall Bladder

Women Only

      Uterus

     Ovaries

      Breast

      D & C

      Tubal Ligation

      Other

Men Only

      Testes

     Prostate

      Vasectomy

      Other

Hospitalizations

Please list dates and reasons for all hospitalizations.

Date                                             Reasons                    

Medications

Please list any medications that you take including prescription and over the counter medicines.

Women Only

Age at first menstrual  period                 

# of times pregnant       

# of living Children       

Date of last PAP Smear

Age when Periods Stopped

Birth Control Method (circle)

Pills/Condoms/ IUD/Sponge

Tubal/Rhythm/Diaphragm

Vasectomy/ None

Women and Men

Do you consider yourself to be:

      Heterosexual (Straight)

      Gay

      Bisexual

Family History

Please check the diseases that your  parents, grandparents, aunts, uncles, brothers, or sisters have or have had.           

      Diabetes

      Asthma

      Stroke

      Cancer

(type)      

      Alcoholism

      Seizures

      Mental Illnesses

      Heart Attack

      High Blood Pressure

      Familial Polyposis

      Other                                                                                                                             

                # years of school completed

Do you have any special interests or hobbies?………………………………………………… ……………..

                Please list

Do you have any concerns which are troubling you?………………………………………….     

                If “yes” please check those concerns:

Hospital Bills                     Family                             Housing/Rent/Heat

Social Security                   Marriage                       Other money matters  (food, clothing, etc.)

Occupation                         Sex                                 Community agencies (Welfare, etc.)

Transportation                   Loneliness                    Emotional Problems/ nerves

Legal                                  Death                             Spiritual

Other

Do you get regular dental checkups?……………………………………………………………………   Yes No

Do you exercise at least three times a week?……………………………………………………………   Yes No

Are you satisfied with your sex life?……………………………………………………………………     Yes No

Do you always wear you seat belt?……………………………………………………………… ……     Yes No

 Do you keep a gun in your home?………………………………………………………………  ……     Yes No

Do you have smoke detectors in your home?…………………………………………………… ……    Yes No

Do you limit sun exposure or use sunscreens (#15 or higher) when tanning?…………………   …   Yes No

Have you ever been physically or sexually abused?……………………………………………  ……   Yes No

Did you ever receive X-ray treatment to your upper body?……………………………………  ……   Yes No

Do you smoke cigarettes?……………………………………………………………………… ………     Yes No

                Packs per day     Years

Do you smoke cigars?……………………………………………………………………………………     Yes No

Do you use snuff or chewing tobacco?…………………………………………………………  ……     Yes No

Do you drink alcohol (beer, wine, or mixed drinks)?…………………………………………………       Yes No

                # drinks per day

                If you have 2 or more drinks a day, please answer these four questions:

                                Have you ever felt a need to cut down on your drinking?…………………   …… Yes No

                                Have you ever been annoyed by criticism of your drinking?………………  …… Yes No

                                Have you ever had guilty feeling about your drinking?……………………  ……  Yes No

                                Do you ever drink a morning eye-opener?…………………………………  ……     Yes No

Do you smoke pot?……………………………………………………………………………  …………    Yes No

Do you use other drugs?………………………………………………………………………  ………      Yes No

The rest of these questions are for you to see if you might be at risk to get AIDS. You do not have to write down your answers, but if any answers are “yes”, you could be at risk for AIDS, and you should talk to your Healthcare provider about it.

Have you had more than one sexual partner in the last year?…………………………………………  Yes No

Has your partner had sex with anyone other than you since you have been partners?………   …   Yes No

Have you or your sexual partner ever used IV drugs?…………………………………………………   Yes No

Have any of your sexual partners had AIDS or a positive HIV test?………………………… …… … Yes No

Have you ever had a venereal disease (VD)?……………………………………………………………  Yes No

Did you ever have a blood transfusion between 1979 and 1985?……………………………… ……   Yes No

Have you had sex without using condoms when unsure of your sexual partners?…………………  Yes No

FOR MEN

Have you had sexual contact with a man in the past ten years?…………….………………………… Yes No

FOR WOMEN

Have any of your sexual partners been bisexual men, or have they had sex with other men?……   Yes No