ࡱ> AC@ objbjT~T~ 78668)Lu,& lL!4$n>>>X>>>uOy 0& ,$$$>z& $ : Strong Internal Medicine Health History Update Patients Name: ________________________________ Todays Date: __________________ Date of Birth: __________________________________ Please help us update your medical record by completing the following questionnaire. Contact Information Home phone #: _________________ Office phone #: _________________ Cell phone #: _____________ How do you prefer to be contacted? _________________________________________ Emergency Contact Name: ____________________________ Relationship: ______________ Phone#___________________ Do you have any special hearing, visual or physical needs: ( Yes ( No If yes, please clarify: _______________________________________________________ Language preference: ( English If not English, please clarify: __________________ In the past year have you had any of the following Operations? ( Yes ( No If yes, what operations did you have? _______________________ Emergency Room visits? ( Yes ( No If yes, for what reason? ____________________________ Hospitalizations? ( Yes ( No If yes, for what reason? __________________________________ 4. Do you have any new medication allergies? ( Yes ( No (Please list medication and reaction) 1) _____________________________________________________________ 2) _____________________________________________________________ 3) _____________________________________________________________ Do you smoke: ( Yes ( No ( In the past? How much? ____ How many years? _____ Have you had exposure to smoke now or in the past? ( Yes ( No How long? __________________ Do you drink alcohol: ( Yes ( No How many alcoholic beverages do you have in a typical day? _____ Have you used illegal or recreational drugs in the past year? ( Yes ( No Do you exercise? ( Yes ( No If yes, what type, how often? ________________________________ Do you wear helmets for sports (i.e. biking, skiing)? ( Yes ( No ( N/A Do you use a seatbelt? ( Yes ( No Do you have smoke detectors in your home? ( Yes ( No Do you have carbon monoxide detectors in your home? ( Yes ( No Are there firearms in your home? ( Yes ( No If yes, are they locked? ( Yes ( No If you are sexually active, do you use contraception? ( Yes ( No ( N/A Do you practice safe sex? ( Yes ( No ( N/A Are there any sexual issues you would like to discuss? _______________________________________ Have you ever been verbally, emotionally, sexually or physically abused or threatened by your partner or anyone else? ( Yes ( No When: ___________________________________________________________________________ Have you often been bothered by feeling down, depressed or hopeless? ( Yes ( No Have you often been bothered by little interest or pleasure in doing things? ( Yes ( No Do you have a Health Care Proxy? ( Yes ( No Do you have a Living Will? ( Yes ( No Please list other health care providers you see: Eye doctor: ________________________________________________________________ Dentist: ___________________________________________________________________ Mental health: _____________________________________________________________ OB-GYN:___________________________________________________________________ Other: ____________________________________________________________________ Do you have any suggestions as to how we might better meet your needs? __________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Reviewed by: _________________________________ Date: ___________________ Thank you for taking the time to complete this form.     Name: _________________________ Page  PAGE 2 of  NUMPAGES 2 CONFIDENTIAL Medical Record #: _______________ Rev 042911 Page  PAGE 1 of  NUMPAGES 2 ./079?@W\aboptw  , . 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