New Patient Health History – Damian Garcia, M.D. Family Medicine

Patient Health History Date:

Damian Garcia, M.D. Family Medicine

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

Name (Last, First, Middle):

( ) M ( ) F DOB:

( ) Single ( ) Partnered ( ) Married ( ) Separated ( ) Divorced ( ) Widowed

Previous or referring doctor:

Date of last physical exam:

Personal Health History

Childhood Illnesses

( ) Measels ( ) Mumps ( ) Rubella ( ) Chickenpox ( ) Rheumatic fever ( ) Polio

Immunizations and dates:

( )Tetanus /date:

( )Pneumonia /date:

( ) Hepatitis /date:

( ) Chickenpox /date:

( ) Influenza /date:

( ) MMR, measles, mumps, rubella /date:

List any other medical problems that other doctors have diagnosed:

Surgeries

Year Reason Hospital

Other hospitalizations

Year Reason Hospital

Have you had a blood transfusion? ( ) Yes ( ) No

Patient Name Date of Birth

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

Name the drug Strength Frequency taken

Allergies to medication

Name the drug Reaction you had

Health Habits and Personal Security Patient name____________________ DoB _________

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.

Exercise

( ) Sedentary (little or no exercise)

( ) Mild exercise (that is to say, climb stairs, walk 3 blocks, golf)

( ) Occasional vigorous exercise (30 minutes at one time)

( ) Regular vigorous exercise (30 minutes at one time, 3 or more times weekly)

Diet Patient name____________________ DoB _________

Are you dieting? ( )Yes ( )No

If yes, are you on a physician prescribed diet? ( )Yes ( )No

# Number of meals you eat in an average day? # Number of snacks?

Rank salt intake ( ) High ( ) Med ( )Low

Rank fat intake ( )High ( )Med ( )Low

Caffeine ( ) None ( )Coffee ( )Tea ( )Coke, DrPepper, etc.

# of cups per day?

Alcohol

Do you drink alcohol? ( )Yes ( )No If yes, what kind?

How many drinks per week?

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 drive after drinking? ( )Yes ( )No

Tobacco

Do you use tobacco? ( )Yes ( )No # of years_______

( )Cigarettes – # packs /day_____

( )Chew – #/day_____

( )Pipe – #/day_____

( )Cigars – #/day_____

( ) Or year quit__________

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 to become pregnant? ( ) Yes ( ) No

If not trying for a pregnancy list contraceptive or barrier or natural method used:

Any discomfort with intercourse? ( ) Yes ( ) No

The illness related to the human immunodeficiency virus (HIV), like AIDS, has come be a major health problem. Risk factors for this illness include the intravenous use of the drug and sexual relations without protection. Would you like you to speak with Dr. Garcia about your risk of this illness? ( ) Yes ( ) No

Personal security Patient name____________________ DoB _________

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 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 Dr. Garcia?   ( ) Yes   ( ) No
FAMILY HEALTH HISTORY   Patient name____________________ DoB _________
Father: Age_____   Significant Health Problems

Mother: Age_____ Significant Health Problems

Maternal Grandmother: Age_____ Significant Health Problems

Maternal Grandfather: Age_____ Significant Health Problems

Paternal Grandmother: Age_____ Significant Health Problems

Paternal Grandfather: Age_____ Significant Health Problems

Sibling: ( )M ( )F :Age_____ Significant Health Problems

Child: ( )M ( )F :Age_____ Significant Health Problems

MENTAL HEALTH Patient name____________________ DoB _________

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 Patient name____________________ DoB _________

Age at onset of menstruation:

Date of last menstruation:________________ Period every _____ days

Heavy periods, irregularity, spotting, pain, or discharge? ( )Yes ( )No

Do you find sexual intercourse painful? ( )Yes ( )No

Age at first intercourse: ______ Number of sexual partners (past and present): ______

Number of pregnancies _____ Number of live births _____

Are you pregnant or breastfeeding? ( )Yes ( )No

Have you had a hysterectomy, or tubes tied, or Cesarean? ( )Yes ( )No

Any urinary tract, bladder, or kidney infections within the last year? ( )Yes ( )No

Any problems with control of urination? ( )Yes ( )No

Have you ever had a pap smear that was not normal? ( )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, pelvic, and rectal exam? ________________

MEN ONLY Patient name____________________ DoB _________

Do you usually get up to urinate during the night? ( )Yes ( )No

If yes, # of times _____

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? ______________

OTHER PROBLEMS Patient name____________________ DoB _________

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

( ) Chest/Heart

Recent changes in:

( ) Head/Neck

( ) Back

( ) Weight

( ) Ears

( ) Intestinal

( ) Energy level

( ) Nose

( ) Bladder

( ) Ability to sleep

( ) Throat

( ) Bowel

( ) Other pain/discomfort:

( ) Lungs

( ) Circulation

Patient name____________________ DoB _________