Care Cross Medical Center
PATIENT INTAKE AND HISTORY FORM
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Name
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Date of Birth
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Preferred Local Pharmacy
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Do you use a mail order pharmacy?
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Yes
No
Do you use a mail order pharmacy? If so, please be sure we have your pharmacy provider information and a copy of your prescription drug card.
Preferred Mail Order Pharmacy
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***Should your information change, please report these changes in your address, phone contact numbers, insurance, or emergency contact, information to the front desk upon check in at future visits***
Reason(s) for coming to the doctor today:
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Has a previous Provider provided treatment for the reason you are being seen today? If yes, please provide Provider information
Do you currently follow up with any other Provider/Specialist? (Example: Cardiology, Neurology, Urology, Endocrinology, Infection disease, Mental Health, Nephrology, Therapy, Optometry, Orthopedics, ENT.) If so please list the provider(s) you are following up with:
Healthcare Maintenance Screening (please list the most recent date if applicable)
Date of Colonoscopy & Who and Where performed or administered?
Date of Mammogram & Who and Where performed or administered?
Date of Last Pneumonia shot: Prevnar or Pneumovax 23 & Who and Where performed or administered?
Date of Last Flu shot & Who and Where performed or administered?
Date of Last Eye Exam & Who and Where performed or administered?
Date of Last Bone Density Study (DEXA) & Who and Where performed or administered?
Date of Last Pap Smear & Who and Where performed or administered?
Date of Last Tetanus Shot& Who and Where performed or administered?
Date of Last Zostavax (Shingles Vaccine) & Who and Where performed or administered?
Problem List/Past Medical History: Have you been diagnosed with any of the following (currently or in the past)?
Abdominal Pain
Abnormal Vaginal Bleeding
Anemia
Anxiety
Arthritis
Asthma
Back Pain
Cancer
Colitis, Ulcerative
COPD
Crohn’s
Deep Vein Thrombophlebitis
Dementia
Depression
Diabetes
Diverticulitis
Dizziness
ED (erectile dysfunction )
GI Bleed
GERD
Gout
Headaches, Chronic
Heart Disease
Heart Murmur
Heart Palpations
Hemorrhoids
Hepatitis
High Blood Pressure
Incontinence
Irritable Bowel
Kidney Stone(s)
Measles
Migraines
MRSA Infection
Mumps
Osteoporosis
Polio
Guillain Barre Syndrome
Prostate Disease
Rash
Rheumatic Fever
Rubella
Scarlet Fever
Seasonal Allergies
Seizure
Sinusitis
Sleep Disorder
Somnolence
Stroke
Tendinitis
Thyroid Disorder
Tuberculosis
Ulcer
Urinary Frequency
Urinary Pain
Vascular Disease, Peripheral
List any other important medical condition(s) and or Surgeries you have had (do not include common colds or flu). Include date or age of initial diagnosis/surgery if possible: (continue on back if necessary) Problem/Previous Diagnosis Date(s) or Age
Allergy History: List known allergies (including medication allergies) and reaction to allergen. Or check one of the boxes below:
or check one of the boxes
No Known Allergies (NKA)
No Known Drug Allergies (NKDA)
Medication History: List any medications and vitamins/minerals/herbs that you are currently taking. Ensure to include Name, Dose, and Frequency of medication(s). or Bring Medication Bottles or Completed
No current Meds
Social History
Do you use tobacco products?
Never used
Former use
Current use
Unknown
How often?
Rare
Social
Daily
What type?
Cigarettes
Chewing Tobacco
Cigars
Are you exposed to “second-hand” smoke?
Yes
No
If yes, please indicate by marking the appropriate boxes:
Minimal
Frequent
Daily
Family members smoke indoors
Family members smoke outdoors only
Please describe your current exercise routine
Inactive
Light
Moderate
Vigorous
Do you drink beverages with caffeine?
Yes
No
What type?
Coffee
Tea
Carbonated Beverages
Have you ever used any illicit drugs?
Yes
No
How often?
Quit
Social Use
Regular Use
Daily Use
What type?
Uses marijuana
Uses cocaine
Uses methamphetamines
Do you drink beverages with alcohol?
Yes
No
How often?
Occasional use
Moderate use
Heavy use
What type?
Beer
Hard Liquor
Wine
What is your most recent primary occupation?
Family History: Has any member of your family been diagnosed with any of the following conditions (include deceased family members)? Father Mother Father’s Mother’s Sister Brother Son Daughter Father Mother Father Mother
Diagnosed with any of the following conditions (include family member)
Heart Disease
High Blood Pressure
Stroke
Cancer
Glaucoma
Diabetes
Epilepsy/Convulsions
Bleeding Disorder
Kidney Disease
Thyroid Disease
Mental Illness
Osteoporosis
List any other important family medical condition(s) you are aware of (do not include common colds or flu). Include date of initial diagnosis if possible: Family member medical condition
Diagnostic Studies: (mark only those that apply)
Angiography (Heart Catheterization:
Diagnostic Study Date: mm/dd/yy and who and where study performed
Cardiac Stress Test
Diagnostic Study Date: mm/dd/yy and who and where study performed
Cardiac Echocardiogram
Diagnostic Study Date: mm/dd/yy and who and where study performed
EKG
Diagnostic Study Date: mm/dd/yy and who and where study performed
EGD:(esophagogastroduodenoscopy)
Diagnostic Study Date: mm/dd/yy and who and where study performed
EEG: (electroencephalogram)
Diagnostic Study Date: mm/dd/yy and who and where study performed
Pulmonary Function Test (PFT)
Diagnostic Study Date: mm/dd/yy and who and where study performed
Sleep Study
Diagnostic Study Date: mm/dd/yy and who and where study performed
Spirometry
Diagnostic Study Date: mm/dd/yy and who and where study performed
Patient Name:
*
Nickname
*
Date of Birth
*
Today’s Date
*
ALLERGIES (List name and reaction)
Medications/Drugs Type of Reaction
Food/Environment Type of Reaction
MEDICATION LIST (Please bring all medications with you to your appointment) (Please include all prescription & non-prescription, medications, vitamins and herbal supplements)
Name of Medication Dose # Per Day
SURGICAL PROCEDURES OR HOSPITALIZATIONS (Please list type/reason and year of surgery or hospitalization)
Hospitalization/Surgeries Reason/Type of Surgery Date
Patient Identification - Write in or attach patient label Name: MRN#: CSN#: Age /Sex:
MEDICAL HISTORY Please check all that apply
[EARS/NOSETHROAT]
Headaches
Visual Problems
Fainting
Dizziness
Seizure
Stroke
Ear Trouble
Hearing Loss
Sinus Trouble
Stuffy Nose
Nose Bleeds
Allergy
Hoarseness
GI/STOMACH Con’t.
Nausea
Diarrhea
Constipation
Hemorrhoids
Bowel Irregularity
Gallbladder Trouble
Hepatitis
Liver Disease
ENDOCRINE
Diabetes
Hypoglycemia
Thyroid Trouble
Goiter
Hot Flashes
Weakness/Fatigue
Sudden Weight Gain/Loss
Abnormal Cholesterol
Trouble Sleeping
PULMONARY/LUNGS
Cough
Wheezing
Pleurisy
Pneumonia
Tuberculosis
Shortness of Breath
Night Sweats
Chest Pain
Coughed up Blood
Emphysema/COPD
Asthma
SKIN
Change in Moles or Warts
Itching/Rash/Hives
Acne
Tumor or Swelling
Skin Cancer
KIDNEY/UROLOGY
Kidney Trouble
Bladder Infection
Incontinence
Difficulty Urinating
Prostate Trouble
Infertility
Impotence
Sexual Problems
Sexual Transmitted Diseases
HEART
Heart Trouble
Heart Murmur
Rheumatic Fever
Palpitation
Irregular Heart Beat
Tire Easily
Angina/Chest Pain
Enlarged Heart
High Blood Pressure
Abnormal EKG
Frequent Ankle Swelling
EMOTIONAL/PSYCHOLOGICAL
Emotional Illness
Difficulty Sleeping
Excessive Worry or Anxiety
Severe Tension
Feeling Worthless
Constant Unhappiness
Mood Swings
Panic Attacks
G.I./STOMACH
Trouble Swallowing
Change in Appetite
Indigestion
Heartburn
Nervous Stomach
Ulcers
Vomiting Blood
Bloody or Dark Stool
Abdominal Pain
Colitis
BONES/JOINTS/MUSCLES
Arthritis
Back Pain
Bursitis
Muscle Cramps
Numbness
Varicose Veins
Muscle Weakness
Phlebitis/Blood Clots
Polio
OTHER
Blood Disorders
Anemia
Cancer
Breast Pain
Breast Abnormality
FAMILY HISTORY
Are you adopted?
Yes
No
Did/does anyone in your family have any of the following conditions? (Check all that apply)
Allergies
Arthritis
Asthma
Back Problems
Blood Diseases
Cancer
COPD
Diabetes
Drug/Alcohol Abuse
Emphysema
Genetic Disorders
Stomach Problems
Kidney Disease
Heart Problems
Hypertension
Lipids
Neurological Disorders
Obesity
Psychiatric
Scoliosis
SIDS
Stroke
Tuberculosis
Thyroid Disorder
Other
No Significant Family History
STATUS
Alive
Deceased
Unknown
Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
SOCIAL HISTORY
Persons living in your household: (List all persons in your household)
Marital Status
Separated
Single
Married
Divorced
Widowed
Partner
Do you drink alcohol?
Never
Occasionally
Daily
If yes, what kind?
Beer
Wine
Liquor
Number of drinks per day
Do you currently use tobacco?
Yes
No
If yes, how many years?
What form of tobacco?
Pipe
Cigarettes
Chew
Cigar
Number per day?
Quit?
Quit date?
Does anyone in your household smoke?
Yes
No
Drug Use (Do not include prescription or over-the-counter medications)
Never
No current use
Occasional
Daily
Uses per week? Uses per day? Types of drugs?
Sexual Activity: (check all that apply)
Inactive
Occasionally
Regularly
Multiple partners
Male partner
Female partner
Do you practice safe sex?
Yes
No
PLEASE MARK IF YES TO THE FOLLOWING
Been in the military
Received a blood transfusion
Drink beverages with caffeine
Are you exposed to hazards at work
Have difficulty sleeping
Have too much stress in your life
Weigh too much or too little
Eat a special diet (high protein, vegan)
Have back problems
Exercise regularly
Always use a seat belt in a car
Do breast or testicular exams regularly
Home has working smoke detector
Are your immunizations up-to-date
Have regular screening exams
Do you get an annual flu shot
Do you eat a balance diet
Advanced Directives: Do you have a
Power of Attorney
Living Will
FOR FEMALE PATIENTS ONLY
Date last menstruated:
Menopause
Age
Any menstrual problems?
Yes
No
Period every_____Days
Number of pregnancies
Number of births
Number of miscarriages
Difficulty with pregnancy
With labor
With delivery
Check if you have had
D & C
Hysterectomy
Toxemia
Cesarean Section
Are you on birth control?
Yes
No
If yes, what type
When was your last Mammogram?
CARE TEAM AND COMMUNICATIONS
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