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MICHIGAN MEDICINE
Family Medicine
Health History Questionnaire – Family Medicine
– 11 Years of Age and Older
NAME:
BIRTHDATE:
CSN:
FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART. DISCARD FORM AFTER ENTRY, USING CONFIDENTIAL RECYCLE. DO NOT SEND TO HIM. Page 1 of 5
VER: A/ HIM: 0 2 /19 Do Not File^ NOT A MEDICAL RECORD DOCUMENT Date of appointment _____/_____/__________ (mm/dd/yyyy) Please fill this form out as completely as possible and bring this to your appointment. If you have filled out this form previously, please enter any changes in your health history that have occurred since your last visit. Past Medical History (Please check any medical problems that you have had in the past) ☐Abnormal pap smear ☐Congestive heart failure ☐Irregular menses ☐Alcoholism ☐COPD (lung disease) ☐Kidney disease ☐Allergies ☐Coronary artery disease ☐Liver disease ☐Anemia ☐Depression ☐Menorrhagia ☐Anxiety ☐Diabetes mellitus ☐Myocardial infarction (heart attack) ☐Arthritis ☐Diverticulitis ☐Nerve/muscle disease ☐Asthma ☐GERD (heartburn) ☐Osteoporosis ☐Blood transfusion ☐Glaucoma ☐Seizures ☐BPH (benign prostatic hyperplasia) ☐Headaches ☐Sickle cell anemia ☐Cancer ☐Heart murmur ☐Sleep apnea ☐Cataracts ☐HIV/AIDS ☐Stroke ☐Clotting disorder ☐Hyperlipidemia (high cholesterol) ☐Substance abuse ☐Colonic adenoma ☐Hypertension (high blood pressure) ☐Tuberculosis ☐Concussion ☐Hypothyroidism ☐Ulcers ☐Other (list)
Past Surgical History (Check any surgeries you have had and the date of surgery if you know it) ☐Appendectomy ☐Cosmetic surgery ☐Prostate surgery ☐Bariatric surgery ☐Eye surgery ☐Small intestine surgery ☐Brain surgery ☐Fracture surgery ☐Spine surgery ☐Breast surgery ☐Hernia repair ☐Tonsillectomy and Adenoidectomy ☐CABG (bypass) ☐Hysterectomy (ovaries removed) ☐Tubal ligation (tubes tied) ☐Cesarean section ☐Hysterectomy (ovaries remain) ☐Valve replacement ☐Cholecystectomy (gall bladder removal) ☐Joint replacement ☐Vasectomy ☐Colon surgery ☐Other (list)
Additional Information:
MICHIGAN MEDICINE
Family Medicine
Health History Questionnaire – Family Medicine
– 11 Years of Age and Older
NAME:
BIRTHDATE:
CSN:
FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART. DISCARD FORM AFTER ENTRY, USING CONFIDENTIAL RECYCLE. DO NOT SEND TO HIM. Page 2 of 5
VER: A/ HIM: 0 2 /19 Do Not File^ NOT A MEDICAL RECORD DOCUMENT Family History Check below to report problems your family members have had. Please state the age when they had the problem if you know it. Please enter the name of the person in the blank. ☐Adopted (unknown/incomplete family history). Mother Father Sister Brother Daughter Son Other (list) Alcohol abuse Aneurysm Asthma Autoimmune disease Birth defects Breast cancer Cancer Colon cancer Colon polyps COPD (lung disease) Deep vein thrombosis Dementia Depression Diabetes Heart disease High cholesterol Hypertension Kidney disease Mental illness Osteoporosis Prostate cancer Pulmonary embolism Stroke Thyroid disease Other (list) Other (list) Other (list) Alive (Yes, No or N/A=Not Applicable)
MICHIGAN MEDICINE
Family Medicine
Health History Questionnaire – Family Medicine
– 11 Years of Age and Older
NAME:
BIRTHDATE:
CSN:
FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART. DISCARD FORM AFTER ENTRY, USING CONFIDENTIAL RECYCLE. DO NOT SEND TO HIM. Page 4 of 5
VER: A/ HIM: 0 2 /19 Do Not File^ NOT A MEDICAL RECORD DOCUMENT Drugs and tobacco Do you use drugs? ☐Yes ☐No If you use drugs, how many times per week? _________ What type(s) of drugs do you use? __________________ Check one of the following about smoking tobacco: ☐Never smoked ☐Exposed to second hand smoke ☐Former smoker ☐Smoke some days ☐Smoke everyday If you smoked or used to smoke, how many packs do or did you smoke per day? _________________ How many years did you smoke / have you smoked? _________________ If you quit smoking, when did you quit? ________________ Check one of the following about smokeless tobacco: ☐Never used ☐Former user ☐Current user If you quit smokeless tobacco, when did you quit? __________________ Are you ready to quit smoking or using smokeless tobacco? ___________________ Do you use e-cigarettes? ☐No ☐Used in the past ☐Not presently ☐Occasionally ☐Daily Sexual activity Are you sexually active? ☐Yes ☐No ☐Not currently If yes, are your partner(s): ☐Male ☐Female ☐Both Type of birth control / protection (check all that you use): Do you have a new sexual partner? __________ Lifestyle On average, how many days per week do you engage in moderate to strenuous exercise? ☐1 day ☐2 days ☐3 days ☐4 days ☐5 days ☐6 days ☐7 days On average, how many minutes do you engage in exercise at this level? ☐0 min ☐10 min ☐20 min ☐30 min ☐40 min ☐50 min ☐60 min ☐70 min ☐80 min ☐90 min ☐100 min ☐110 min ☐120 min ☐130 min ☐140 min ☐150+ min ☐Not having sex (abstinence) ☐Condom ☐Injection ☐IUD (intrauterine device) ☐Oral contraceptives (Pill) ☐Partner vasectomy ☐Patch ☐Post-Menopausal ☐Vasectomy ☐None ☐Other (specify):
MICHIGAN MEDICINE
Family Medicine
Health History Questionnaire – Family Medicine
– 11 Years of Age and Older
NAME:
BIRTHDATE:
CSN:
FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART. DISCARD FORM AFTER ENTRY, USING CONFIDENTIAL RECYCLE. DO NOT SEND TO HIM. Page 5 of 5
VER: A/ HIM: 0 2 /19 Do Not File^ NOT A MEDICAL RECORD DOCUMENT Safety Do you have a gun at home? ☐Yes ☐No Socioeconomic Employment Occupation: ___________________________________________ Employer: _____________________________________________ Demographics Marital status: ☐Divorced ☐Legally separated ☐Married ☐Significant other ☐Single ☐Widow ☐Unknown ☐Other (specify): ________________________ Spouse name: ___________________________________ Number of children: _______________________________ Years of education: ________________________________ Review of Systems • Please circle which symptoms you have currently. General fever decreased/no energy loss appetite unintended weight gain/loss none Head headache injury none Eye visual change crossed discharge redness puffiness none Ear difficulty with hearing pain discharge none Nose runny nose nasal congestion nose bleed none Mouth/throat sore throat difficulty swallowing dental problems none Lung shortness of breath coughing chest pain wheezing sputum blood in sputum none Heart pale cyanosis chest pain leg swelling faint none Gastrointestinal abdominal pain nausea vomiting diarrhea constipation distention blood in stool black/tarry stool none Genitourinary painful urination urine retention incontinence difficulty urinating blood in urine none Musculoskeletal deformities joint pain joint swelling difficulty in moving none Neurologic dizziness weakness hand shakiness seizures none Skin rash itching color change easy bruising/bleeding change in mole none Psychiatric frequent mood change^ nervousness^ tension^ feeling down unable to sleep at night none _____________________________________________________ _____/_____/__________ (mm/dd/yyyy) Printed name of person who completed this form Date
