Microsoft word - level iv - kendra salters.docx

Original Date:
Dates Revised:
HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential and will become part of your medical record. Name (Last, First, M.I.): Salters,
DOB: 4/5/1984
Marital status: … Single … Partnered … Married … Separated … Divorced … Widowed
Previous or referring doctor:
Date of last physical exam:
PERSONAL HEALTH HISTORY
Childhood illness:
X Measles … Mumps … Rubel a X Chickenpox … Rheumatic Fever … Polio
Immunizations and
X Tetanus
X Pneumonia
X Hepatitis
X Influenza
X MMR Measles, Mumps, Rubella
List any medical problems that other doctors have diagnosed
Diabetes Type II
Hypertension
Surgeries
Other hospitalizations
Have you ever had a blood transfusion?
List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Allergies to medications
HEALTH HABITS AND PERSONAL SAFETY
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL. Exercise
… Mild exercise (i.e., climb stairs, walk 3 blocks, golf) … Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) X Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
X Yes … No
If yes, are you on a physician prescribed medical diet? Caffeine
Are you concerned about the amount you drink? Do you currently use recreational or street drugs? Have you ever given yourself street drugs with a needle? X Yes … No
If not trying for a pregnancy list contraceptive or barrier method used: Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness? Personal
Do you have an Advance Directive or Living Will? X Yes … No
Would you like information on the preparation of these? 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 your provider? FAMILY HEALTH HISTORY
Children
X M
… F 49 HTN,
Grandmother
Grandfather
Grandmother
Grandfather
MENTAL HEALTH
Do you have problems with eating or your appetite? Have you ever seriously thought about hurting yourself? WOMEN ONLY
Heavy periods, irregularity, spotting, pain, or discharge? Number of pregnancies __2__ Number of live births __1__ Have you had a D&C, hysterectomy, or Cesarean? Any urinary tract, bladder, or kidney infections within the last year? X Yes … No
X Yes … No
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period? Experienced any recent breast tenderness, lumps, or nipple discharge? Date of last pap and rectal exam? 4/4/2009 Do you usually get up to urinate during the night? Do you feel pain or burning with urination? Do you feel burning discharge from penis? Has the force of your urination decreased? Have you had any kidney, bladder, or prostate infections within the last 12 months? Do you have any problems emptying your bladder completely? Any difficulty with erection or ejaculation? OTHER PROBLEMS
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain. X Skin – rash on back
X Intestinal – abdomen pain

Source: http://faculty.gvsu.edu/kconweb/MotivationalInterviewing/LevelIV_Kendra%20Salters.pdf