Ob / Gyn Annual Health History Form Page 2
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1
2Family History
Grandparent
Father
Mother
Aunts
Your Brother/Sister
Social History
Marital Status:
Single
Married
Divorced
Widowed
Separated Spouse’s Name: ____________________________
Living arrangements
Alone
Family/Significant Other
Assisted Living
Daily help needed for self care
Name of care giver ______________________ Children: How many? _______ Ages: _________________
Occupation: _______________________
FT
PT
Self
Retired from:____________
Activities of Daily Living:
Level of Education:
HS / GED
Tech / A.A
B.S. / B.A. or higher
Any difficulty with?
Speech/Communication
Diet:
Unrestricted
Low fat
Low carb / diabetic Caffeine:
No
Yes Type/Amt: ______
Memory
Dressing
Sleep: # of hours per night _______ Problems: Falling / Staying asleep?
No
Yes
Bathing
Household Duties
Exercise:
No
Yes Type: ___________
Once a week
2-3x/wk
Daily
Fall Risk: Do you have concerns about falling?
No
Yes Do you use any balance/mobility devices? ___________________________
Learning Needs: Are there any needs (learning, ethnic, cultural, or spiritual) we should know about that might impact your care or your
ability to understand treatments / procedures/ educational materials?
No
Yes Please explain: ________________________________
_________________________________________________________________________________________________________________
Abuse / Neglect: Are you experiencing neglect and/or conflict in your family and/or relationships?
No
Past
Current
Tobacco:
Never
Past
Current
Alcohol:
Never
Past
Current
Street Drugs:
Never
Past
Current
What? ________________
Started: __________ Quit: _________
_____ # of drinks per
Day
Week
Started: __________ Quit: _________
Packs per day? ______
Smoke
Chew
Month
General:
Lungs:
Abdomen:
Musculoskeletal
Anxiety/Depression
Cough
Abnormal stools
Back pain
Fatigue
Trouble breathing
Nausea, Vomiting
Joint pain / arthritis
Fever or chills
Wheezing
Pain
Difficulty with balance
Migraines
______________
Rectal bleeding
Difficulty with walking
Weight loss / gain
______________
Date of last fall __________
Heart:
______________
______________
Chest pain
Breast:
Ears/Eyes/Throat:
Irregular/rapid heartbeat
Breast lump
Skin
Ear pain or ringing
Pain or swelling in legs
Breast pain
Bruising
Frequent nose bleeds
______________
Nipple discharge
Changing mole
Nasal/Sinus drainage
If yes, what was done?
Skin rash
Vision problems
____________________
______________
______________
Do you perform breast
Self-exam each month?
YES
NO
Place patient sticker here or handwrite
______________
Name: ___________________________
Cover/AHH
Page 2/2
DOB: ____________________________
Rev 04-2011
Form 0301
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Parent category: Medical