Robert A. Mesropian Center for Community Care

a Department of Alice Peck Day Memorial Hospital

Annual Health History Update Form

Please take a moment to update your medical history

Name: ______Birth Date: ______Today’s Date:______

Do you have any allergies? q yes q no If yes :
Have you had any changes in your family history? q yes q no If yes :
Are there any other healthcare providers you see on a regular basis? qyes qno If yes :
Have you had any hospitalizations or surgeries or since your last visit? qyes qno If yes :

Have you had any of the following in the past year? qBone Density/DEXA qColon screen q Eye exam

qDental exam qTetanus shot qPneumonia shot qShingle shot qMammogram qPap smear

Please check ONLY those that apply

Head, Eyes, Ears, Nose & Throat / Intestinal
q / Frequent or severe headaches / q / Cough when laying down
q / Dizziness or fainting spells / q / Poor appetite
q / Blurred or double vision / q / Frequent episodes of nausea or vomiting
q / Change in hearing or ringing in your ears / q / Yellow skin or eyes
q / Earaches / q / Difficulty swallowing
q / Frequent or severe sinus infections / q / Frequent indigestion or heartburn
q / Nose bleeds / q / Change in size, shape or texture of your stools
q / Frequent or severe sore throat / q / Change in regularity of your bowel movements
q / Recurrent sores in your mouth / q / Vomiting blood or what looked like ‘coffee grounds’
q / Bleeding gums / q / Black tarry stools
q / Persistent hoarse voice / q / Rectal bleeding/blood in your stools
Heart/Lungs / Muscle/Bones/Joints
q / Chest pain or pressure / q / Any problems with exercise
q / Thumping or racing in your heart / q / Frequent or severe backaches
q / Chronic cough / q / Stiff or swollen joints
q / Cough with sputum or blood / q / Muscle spasms
q / Shortness of breath with very mild exercise / q / Redness or heat in joints
q / Difficulty breathing when lying down flat
q / Swelling in your hands or feet / Neurological
q / Cramps in your legs while walking or at night / q / Seizures or feeling ‘out of control’
q / Change in strength of arms or legs
Hormones / q / Change in speech
q / Hot flashes / q / Trembling of hands or feet
q / Increased in frequency of urination / q / Difficulty walking or keeping balance
q / Change in thirst / q / Loss or change in sensation
q / Change in skin or hair texture
q / Feeling either hot or cold when others are comfortable
q / None of the above
q / None of the above / *Continued on reverse side
Please check ONLY those that apply
Urinary/Genitals / Other
q / Pain with urination / q / Skin changes- rash, moles, lesions
q / Dark, tea colored urine / q / Currently or in last year seen a counselor
q / Blood in your urine / q / Tearfulness
q / Loss of urine when coughing/sneezing / q / Feel irritated or worried
q / Difficulty in starting urination/weak stream / q / Feel sad or down
q / Males- Check for lumps in testicles / q / Trouble falling or staying asleep
q / Males- Difficulty maintaining an erection / q / Thoughts of suicide or harming yourself
q / Discharge from your penis or vagina / q / Tiredness without apparent reason
Are you sexually active? q yes q no / q / Unexpected change in weight
q / Satisfied with your sex life / q / Night sweats
q / Pain with intercourse / q / Significant concerns about work or family
q / Have female partners / q / Ever been hit, hurt, frightened or neglected in your home
q / Have male partners / q / Ever drink alcoholic beverages
Method of birth control ______/ q / Ever felt guilty about your drinking
q / Use condoms / q / Ever felt the need to cut down on your drinking
q / Ever felt annoyed by criticism of your drinking
Do you: / q / Ever use ‘street drugs’ such as marijuana, cocaine, heroin or narcotic pain medications?
q / Do self skin exams
q / Smoke / q / None of the above
If so, number of packs per day: ______
number of years: ______/ How many glasses of alcohol do you drink in a week? ______
q / Have a special diet / How many caffeinated beverages do you drink per day? ______
If so, what kind? ______/ How many servings of fruits do you eat daily? ______
q / Use sunscreen / How many servings of vegetables do you eat daily? ______
q / Get a flu shot / How many meals a day do you eat? ______
q / Do self breast exams / What type of exercise(s) do you do? ______
______
q / Wear your seat belt / How often do you exercise? ______
q / Have guns in your home / For how long do you exercise each time? ______
q / None of the above

Please list any other health concerns &/or changes that were not listed above: ______

______