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Care and Cure Clinic
Welcome to the
Care and Cure Clinic
. If you are
a new patient or have not seen us for 2 years, please complete the following
page
health history prior to your appointment. Feel free to ask for assistance from
the staff or your provider if you are unsure how to answer a
question.
First Name:
Last Name
Date:
What name would you like to be called?
Pharmacy Name:
Phone Number:
Date of birth:
/ /
_
mm/dd/year Home phone:
Work phone:
Email:
Cellular phone:
Preferred Method of Contact:
In case of emergency, contact:
Phone:
Relationship:
Please state reason for today’s visit:
Birthplace:
Is Houston area your primary home?
Education: middle school
high school
college degree
post college degree
Occupation:
Are you a caregiver for a family member? Yes
No
If yes, briefly describe your role
Married?
Yes
No How many years?
Occupation (spouse/partner):
Allergies to Medications
Current Medications
(please include over the counter medications and food supplements
)
Drug Name Dose How Often? Drug Name Dose How Often?
Your Health History (Check if you have had any of the following) Abnormal Heart Rhythm Allergies/Seasonal/ Environmental
Anemia Anxiety/Stress Asthma Arthritis Atrial Fibrillation Back Pain Colitis or Crohn's Disease Cancer (Any type) Chronic Bronchitis Chronic Pain Chronic Kidney Disease Depression Diabetes Diverticulitis Emphysema/COPD Gall Bladder Disease Gout Headaches/Migraines Heart Attack Heartburn (GERD) Heart Failure Heart Murmur Hepatitis High Blood Pressure High Cholesterol HIV/AIDS IBS Kidney Failure Kidney Stones Mental Illness Obesity Osteoporosis Peripheral Vascular Disease Seizures/Epilepsy
Sleep Apnea Stomach Ulcers Stroke Thyroid Disease Urinary Tract Infection
Please list any hospitalizations and surgeries with approximate dates:
Have you had blood transfusions: χ Yes or χ No How many hours a night do you sleep? Any trouble falling asleep? χ Yes χ No Any trouble staying asleep? χ Yes χ No Have you been told you snore loudly? χ Yes χ No If so, do you fall asleep easily during the day?
In the past 7 days, how many times have you used an over-the-counter or prescription sleep aid? Preventive Health History Check if you have had any of the following and provide date (month and year and/or results)
Colonoscopy Cardiac Stress Test Mammogram Bone Density Pelvic and Pap Cholesterol Screening Date Results
Vaccines
Tetanus (Td or Tdap) Pneumonia Zostavax (Shingles) Hepatitis B Influenza (flu) Date Prostate Antigen Test (PSA)
Have you traveled or are you planning a visit outside of the United States? χ Yes χ No If yes, list locations and dates: Is medical information presented to you in an easy to understand manner? χ Never χ Occasionally χ Sometimes χ Always
How often are medical forms difficult to understand and fill out? χ Never χ Occasionally χ Sometimes χ Always
How often do you have problems learning about your medical condition because of difficulty understanding written information? χ Never χ Occasionally χ Sometimes χ Always
What are your hobbies?
How would you rate your diet? χ Excellent χ Good χ Fair χ Poor
Do you have any food allergies or intolerance? χ Yes χ No Specify:
Do you follow a special diet or nutrition plan? χ Yes χ No Specify:
Tobacco use: Smoking history: χ Never smoked χ Started (age) χ Stopped (age) How many packs per day do you now smoke now in the past
Do you dip or chew tobacco? χ Yes χ No
Do you drink alcoholic beverages? χ Yes χ No If yes, please estimate how much you drink:
Glasses/cans per day/week/month (circle one)
Have you ever had a drinking problem? χ Yes χ No When was your last drink?
How many cups of coffee, tea, or other caffeine products (like Coke) do you drink daily?
Do you use, or have you used marijuana, cocaine, IV drugs, or other street drugs? χ Yes χ No Do you consider yourself the appropriate weight? χ Yes χ No If No, what do you think an appropriate weight would be for you?
Describe your regular physical activity or exercise program: Type: Frequency: days per week Duration: minutes Intensity: χ Low χ Moderate χ High
Do you see a dentist? χYes χ No Last visit date:
Do you see an eye doctor? χ Yes χ No Last visit date:
How often do you wear seat belts? χ Always χ Occasionally χ Never
Were you adopted? χ Yes χ No if no, complete the following table: Family History Maternal Paternal Mother Father Grandparents Grandparents Brother Brother Sister Sister Breast Cancer Colon Cancer Diabetes Heart Attack High Blood Pressure High Cholesterol Lung Cancer Prostate Cancer Skin Cancers Stroke Other (Please Specify):
If your mother, father, brothers or sisters are deceased, please list their age at the time of death and the cause:
How do you rate your overall health: χ Excellent χ Good χ Fair χ Poor Please check any of the following that apply to you: YES NO History of STI’s (sexually transmitted infections):
(HPV, genital warts, chlamydia, herpes, gonorrhea, syphilis, other _) _Have you ever been tested for HIV disease? If Yes, what year? If No, would you like to be tested? χ Yes χ No
Are you sexually active? χ Yes χ No Age of first sexual encounter (intercourse) If yes: Are your sexual partners χ Male χ Female χ Both YES NO Do you feel safe in your current relationship?
Do you feel afraid of a partner/spouse?
Have you ever, or are you currently suffering abuse (slapping, hitting, choking, yelling, threatened) in your relationship? If Yes:
Are your friends and family aware of any problems/abuse in your relationship?
Do you have an emergency escape plan and somewhere safe to go?
Over the past 2 weeks, how often have you been bothered by any of the following problems: Little interest or pleasure in doing things χ Not at all χ Several days χ More than half the days χ Nearly everyday
Feeling down, depressed or hopeless χ Not at all χ Several days χ More than half the days χ Nearly everyday
Systems Review Please check any of the following that you have experienced or are a concern to you
Constitutional
Weight Gain/Loss ο Fatigue ο Fever or Sweats ο Headache ο
Eyes
Glasses/Contacts ο Cataracts ο Double Vision ο Glaucoma ο
Respiratory
Cough ο Coughing Blood ο Wheezing ο Shortness of Breath ο
Gastrointestinal
Heartburn ο Nausea/Vomiting ο Constipation ο Diarrhea ο
Lymph/Immune
Easy Bruising ο Gums Bleed Easily ο Enlarged Glands ο Hay Fever/Allergies ο
Musculoskeletal
Joint Pain.Swelling ο Back Pain ο Muscle Pain ο Difficulty Swallowing ο
Skin
Ears,Nose,Throat
Difficulty Hearing ο Abdominal Pain Black Stools ο Rash/Sores ο ο Abnormal Moles ο ο Ringing in Ears ο Abnormal Masses ο ο Vertigo ο Sinus Pain ο Nasal Congestion ο Frequent Sore Throats ο Hoarseness ο
Cardiovascular
Chest Pain ο Palpitations ο Fainting Spells ο Dizziness ο Difficulty Lying Flat ο Swelling in Legs ο Cramps, Coldness in Legs ο
Genitourinary
Frequent Urination ο Difficult Urination ο Burning on Urination ο Nightime Frequency ο Blood in Urine ο Abnormal Discharge ο Genital Skin Lesions ο
Endocrine
Loss of Hair ο Heat/Cold Intolerance ο Weight Gain ο Sexual Dysfunction ο
Neurological
Weakness/Paralysis ο Numbness ο Tremors ο Memory Loss ο
Psychiatric
Mood Swings ο Difficulty Sleeping ο Anxiety/Depression ο
W
omen
Vaginal discharge or infections Painful intercourse or sexual difficulty Abnormal bleeding Do you douche vaginally?
ο ο ο ο If so, how often ο Breast lump, pain or nipple discharge ο History of abnormal Pap Smears ο
Date of first day of last menstrual period? Age at first period?
Age at menopause?
Number of days of menstrual flow per cycle?
Flow (check one) ο Mild ο Moderate ο Heavy Number of days between successive periods? Number of pregnancies? Number of Children? History of female surgeries: ο Hysterectomy ο Tubes Tied ο D&C ο Other
MEN
Discharge from penis ο Lump or pain in testicles ο Problems with erections ο Decreased sex drive/desire ο Difficulty with urine stream ο
Please list recent past physicians with address and specialty who have cared for you:
1.
2.
3.
Who completed this form? Patient Relative If so, what relationship? Friend
Patient Signature Date
THANK YOU for completing this 6 page Health History. It will help us provide YOU with better
care.
Do
not
write below this
line
I reviewed this patient’s history form.
Health Care Provider’s Signature Date
Submit
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New patient Registration Form
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