Gwen’s Speech Therapy, Inc.

Adult Health History for New Patients

Name:  _____________________________________        Date of Birth: _____________________

Address: ____________________________________        Phone: __________________________

___________________________________________        Date form completed: ______________

Main reason for visit:  ____________________________________________________________

Other health concerns: ___________________________________________________________

REVIEW OF SYMPTOMS: Please mark the box and/or circle any persistent symptoms you have had in the past few months. Read through every section and check “no problems” if none of the symptoms apply to you. List other concerns above.

General

___ Unexplained weight loss / gain ___ Unexplained fatigue / weakness

___ Fall asleep during day when sitting

___ Fever, chills

___ No problems

 Skin

___ New or change in mole

 ___ Rash / itching

___ No problems

Breast

 ___ Breast lump / pain / nipple discharge

___ No problems

Ears/Nose/Throat

___ Nosebleeds, trouble swallowing

 ___ Frequent sore throat, hoarseness

___ Hearing loss / ringing in ears ___ No problems

 Eyes

___ Change in vision / eye pain / redness

___ No problems

Cardiovascular

 ___ Chest pain / discomfort

___ Palpitations (fast or irregular heartbeat)

___ No problems

Respiratory

 ___ Cough / wheeze

 ___ Loud snoring / altered breathing during sleep

 ___ Short of breath with exertion ___ No problems

 Gastrointestinal

 ___ Heartburn / reflux / indigestion ___ Blood or change in bowel movement

 ___ Constipation

 ___ No problems

Genitourinary

___ Leaking urine

 ___ Blood in urine

 ___ Nighttime urination or increased frequency

 ___ Discharge: penis or vagina ___ Concern with sexual function ___ No problems

Musculoskeletal

___ Neck pain

___ Back pain

___ Muscle / joint pain _____________

 ___ No problems

Endocrine

___ Heat or cold sensitivity

 ___ No problems

Hematologic/Lymphatic

 ___ Swollen glands

___ Easy bruising

___ No problems

Neurological

  ___ Headache

  ___ Memory loss

___ Fainting

___ Dizziness

___ Numbness / tingling

___ Unsteady gait

___ Frequent falls

___ No problems

Allergic/Immune

___ Hay fever / allergies

___ Frequent infections

___ No problems

 Psychiatric

 ___ Anxiety / stress / irritability

___ Sleep problem

___ Lack of concentration

 ___ No problems

Women only

___ Pre-menstrual symptoms             (bloating cramps, irritability)

___ Problem with menstrual period ___ Hot flashes / night sweats

 ___ No problems

MEDICATIONS: Please list (or show us your own printed record) all prescriptions and non-prescription medications, vitamins, home remedies, birth control pills, herbs, inhalers, etc. Use the back of this form if you need more room and let us know you wrote there.

 TAKE NO MEDICATIONS

Medication                         Dose (e.g. mg/pill)                         How many times per day? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 Allergies or intolerance to medications (include type of reaction): _____________________________________________________________________________________

 NONE

PERSONAL MEDICAL HISTORY: Do you have now (current) or have you had (past) any of the following conditions?

Condition

Current

Past

Comments

Alcohol / Drug abuse

 

 

 

Allergy (Hay Fever)

 

 

 

Anemia

 

 

 

Anxiety

 

 

 

Arthritis (Rheumatoid)

 

 

 

Arthritis (Osteoarthritis)

 

 

 

Asthma

 

 

 

Bladder / Kidney Problems

 

 

 

Blood Clot (leg)

 

 

 

Blood Clot (lung)

 

 

 

Blood Transfusion

 

 

 

Breast Lump (benign)

 

 

 

Cancer Breast

 

 

 

Cancer Colon

 

 

 

Cancer Other Type

 

 

 

Cancer Ovarian

 

 

 

Cancer Prostate

 

 

 

Cataracts

 

 

 

Chicken Pox

 

 

 

Colon Polyp

 

 

 

Coronary Artery Disease

 

 

 

Depression

 

 

 

Diabetes (adult onset)

 

 

 

Diabetes (childhood onset)

 

 

 

Diverticulosis

 

 

 

Emphysema

 

 

 

Fractures (broken bones)

 

 

Where?

Gallbladder Disease

 

 

 

Gastroesophageal Reflux (Heartburn/GERD)

 

 

 

Glaucoma

 

 

 

Gout

 

 

 

Gynecological Conditions (Endometriosis)

 

 

 

Gynecological Conditions (Fibroids)

 

 

 

Gynecological Conditions (Other)

 

 

 

Heart Attack

 

 

 

Hepatitis – Type A

 

 

 

Hepatitis – Type B

 

 

 

Hepatitis – Type C

 

 

 

Hepatitis – Other

 

 

 

High Blood Pressure

 

 

 

High Cholesterol

 

 

 

Hip Fracture

 

 

 

Irritable Bowel Syndrome

 

 

 

Kidney Disease / Failure

 

 

 

Kidney Stones

 

 

 

Liver Disease

 

 

 

Migraine Headaches

 

 

 

Osteoporosis

 

 

 

Pneumonia

 

 

 

Prostate (enlargement)

 

 

 

Prostate (nodules)

 

 

 

Seizure / Epilepsy

 

 

 

Skin Condition (Eczema)

 

 

 

Skin Condition (Psoriasis)

 

 

 

Skin Condition (Abnormal Moles)

 

 

 

Sleep Apnea

 

 

 

Stomach Ulcer

 

 

 

Stroke

 

 

 

Thyroid (Nodule)

 

 

 

Thyroid High (Overactive) / Hyperthyroidism

 

 

 

Thyroid Low (Underactive) / Hypothyroidism

 

 

 

Other (list)

 

 

 

SURGICAL HISTORY – Please check off any procedure or surgeries. List any abnormal finding or complications.  NONE

Surgical Procedure

Year

Comments

 

 

 

 

 

 

 

 

 

 

 


Tobacco Use

Smoke Cigarettes:    Never    No    Yes

(If you never smoked please go to alcohol use questions now)

Quit date:  __________  How many years did you smoke?  ___________

Approximately how many packs a day did you smoke?  ______________

Current smoker: Packs/day: ______ # of years: ______

Other tobacco (please circle): Pipe     Cigar     Snuff     Chew

Alcohol

Do you drink alcohol?  No     Yes   # drinks/week: ________

Beer     Wine    Liquor

Drug use

Do you use marijuana or recreational drugs?   No     Yes

Have you ever used needles to inject drugs?    No      Yes

Exercise

Do you exercise regularly  No     Yes  

What kind of exercise?    ______________________________________

How long?  ______________ How often ____________

Have you completed an Advance Directive for Health Care, Living Will or POLST (Physician Orders for Life Sustaining Therapy)?  NO     YES

Do you have a Power of Attorney?    No   Yes     Name ________________

Social History

Occupation (or prior occupation):  _______________________________________

Retired/unemployed/leave of absence/disabled (circle one)

Employer:  __________________________________

Years of education or highest degree: ______________________________

Marital Status (circle one):  single/married/divorced/widowed/other

Spouse's Name: _________________________

Number of children: _________  Grandchildren _________ Great grandchildren ______

Who lives at home with you? _____________________________

Leisure activities? ____________________________________________

WOMEN’S HEALTH HISTORY

Total number of pregnancies: _______ Number of births: ________

Date (month/day if known) of last menstrual period if you are still menstruating: ____________

Age at beginning of periods (menstruation): _________

Age at end of periods (menopause): _________


Health Insurance

Name of Insurance Company  _______________________________

Account Number __________________________________________

Name insurance is under ___________________________________

Phone __________________________________________________

Medicare No. ____________________________________________

Medicaid No. _____________________________________________

Additional Insurance  _______________________________________

Social Security No. ______________________________________

People who can receive information regarding your medical/speech therapy care

Name

Relationship

Phone

___________________________

_______________

____________

___________________________

_______________

____________

___________________________

_______________

____________

People who should be contacted in case of emergency

Name

Relationship

Phone

___________________________

_______________

____________

___________________________

_______________

____________

___________________________

_______________

____________

“Communication is the Key!”