Transcription of Family Practice of West Volusia, P.A. CAsEy V. …
1 Family Practice of west Volusia, BRUCE G. RANKIN, MARy ThEREsA IzzO, ARNP, DEBORAh DARNEll, ARNP. CAsEy V. WIlsON, sTEPhANIE sTOVAll, MEDICAl hIsTORy Phone: Home_____ Work_____. Today's Date: _____ Address:_____. Name: _____ City:_____ State:_____ Zip: _____. Age:_____ Date of Birth:_____ Sex: M F _____ Birth Place:_____ Occupation: _____. SS # _____ Race: _____. Please circle No or Yes. Have you ever: Been Hospitalized ..No ..Yes Been refused employment for health ..Yes Injured on the Job ..No ..Yes Received Disability ..Yes Workers Compensation ..No ..Yes Been refused life insurance for health reasons.
2 No ..Yes General Physical ..No ..Yes Received Military Pension for medical reasons ..No ..Yes Present Medical Insurance: _____. Date last seen by a doctor: _____ Doctor's Name: _____. Person to contact in the event of an emergency: Name: _____. Phone # _____ Address _____. IF LIVING IF DECEASED PERsONAl hIsTORy HABITS: Do you: Family HISTORY NAMES AGE HEALTH AGE CAUSE Work ..Yes Mother If Yes, how many hours per week_____. Sleep well ..No ..Yes Father Eat a regular diet ..No ..Yes Maternal Grandmother Eat a special diet ..No ..Yes If Yes, what _____. Maternal Grandfather Use alcoholic beverages.
3 No ..Yes Paternal Grandmother If Yes, what and how much_____. Paternal Grandfather How often _____. Smoke ..No ..Yes Brothers/Sisters If Yes, what and how much_____. How many years _____. Have you EVER ..Yes If yes, when did you quit _____. Drink coffee regularly ..No ..Yes Children How many cups per day _____. WEIGHT. Now_____ lbs. 1 year ago _____ lbs. Maximum weight _____ lbs. When _____. Exercise daily ..No ..Yes HEIGHT_____. LIST ALLERGIES: _____. _____. LIST CURRENT MEDICATIONS (including over the counter): _____. _____. _____. _____. LIST ILLNESSES AND DATES:_____.
4 _____. _____. LIST HOSPITALIZATIONS AND DATES: _____. _____. _____. _____. LIST SURGERIES AND DATES: _____. _____. _____. REV Family Practice of west Volusia, BRUCE G. RANKIN, MARy ThEREsA IzzO, ARNP, DEBORAh DARNEll, ARNP. CAsEy V. WIlsON, sTEPhANIE sTOVAll, Family HISTORY ..Yes _____. When completing the following, whenever you answer YES, fill in the Head Trauma ..No ..Yes _____. relationship and approximate age. EXAMPLE: Asthma .. Yes Sister 4 EYES, EARS, NOSE AND THROAT - DO YOU WHEN. Has any blood relative ever had: (Circle No or Yes) WHO AGE Wear glasses ..No.
5 Yes Date of last exam _____. Cancer (including Leukemia)..No ..Yes _____ _____ Have full dentures ..No ..Yes Partial dentures ..No ..Yes Tuberculosis ..No ..Yes _____ _____ Date of last dental exam_____. Diabetes ..No ..Yes _____ _____ Are your teeth in good repair?..No ..Yes Heart ..Yes _____ _____ Do you use a hearing aid? ..No ..Yes Heart Attack ..No ..Yes _____ _____ Have you ever had a detached retina? ..No ..Yes _____. High Blood Pressure ..No ..Yes _____ _____ Do you have Glaucoma? ..No ..Yes _____. Stroke ..No ..Yes _____ _____. Epilepsy ..No ..Yes _____ _____ CARDIO AND PERIPHERAL VASCULAR: Bleeding Disorder.
6 No ..Yes _____ _____ Have you ever had: WHEN. Asthma ..No ..Yes _____ _____ Rheumatic fever or heart ..Yes _____. Liver Disease ..No ..Yes _____ _____ High blood ..Yes _____. Migraine ..Yes _____ _____ Heart ..Yes _____. Alcoholism ..No ..Yes _____ _____ Chest pain or angina ..No ..Yes _____. Emphysema ..No ..Yes _____ _____ Palpitation or fluttering ..Yes _____. Stomach or Duodenal ..Yes _____ _____ Swelling of feet or ankles ..No ..Yes _____. Kidney ..Yes _____ _____ Shortness of breath on exertion ..No ..Yes _____. Glaucoma ..No ..Yes _____ _____ Have you ever been anemic.
7 No ..Yes _____. Sickle Cell ..Yes _____ _____ Have you ever had a blood transfusion ..No ..Yes _____. AIDS ..No ..Yes _____ _____ Do you have a pacemaker ..No ..Yes _____. PAST HISTORY - ILLNESS: Have you ever had: WHEN RESPIRATORY: Have you ever had: WHEN. Chicken Pox .. _____ Pneumonia or ..Yes _____. Gonorrhea or _____ Hay fever ..No ..Yes _____. Malaria .. _____ Asthma ..No ..Yes _____. Tuberculosis .. _____ Night ..Yes _____. Cancer .. _____ Spit up blood ..No ..Yes _____. Herpes .. _____ Shortness of breath ..No ..Yes _____. High Blood Pressure .. _____. _____ GASTROINTESTINAL: Have you ever had: WHEN.
8 Anesthesia problems? .. _____ Stomach trouble or ulcers ..No ..Yes _____. Have you ever been advised to have Vomiting of blood ..No ..Yes _____. an operation which was not done? .. _____ Indigestion or ..Yes _____. Why wasn't it done? _____ Liver or Gallbladder disease ..No ..Yes _____. Colitis or bowel disease ..No ..Yes _____. NERVOUS & MENTAL (NEURO): Have you ever had: WHEN Constipation ..No ..Yes _____. Frequent or severe headaches .. _____ Take laxatives frequently ..No ..Yes _____. Loss of _____ Recent change in bowel action ..No ..Yes _____. Dizzy or fainting _____ Recent prolonged.
9 Yes _____. Convulsions or paralysis .. _____ Recent change in appetite/eating habits ..No ..Yes _____. _____ Hemorrhoids or rectal bleeding ..No ..Yes _____. Psychiatric admission .. _____ Black bowel movements ..No ..Yes _____. Nervous breakdown .. _____ Have you ever had a hernia? ..No ..Yes _____. Family Practice of west Volusia, BRUCE G. RANKIN, MARy ThEREsA IzzO, ARNP, DEBORAh DARNEll, ARNP. CAsEy V. WIlsON, sTEPhANIE sTOVAll, Date of last breast exam _____. MUSCULOSKELETAL: Date of last mammogram _____. Do you have or have you ever had: WHEN Are you pregnant at this time?
10 No ..Yes Arthritis .. _____ No. of live births _____ No. of still births _____. Sciatica or low back pain .. _____ No. of premature births _____ No. of miscarriages _____. Polio or Meningitis .. _____ No. of Cesarean Sections _____. Fractures (broken bones) .. _____ Diabetes during pregnancy ..No ..Yes Where _____ Complications ..No ..Yes Can you care for all your own needs? .. _____. If no, why _____ IMMUNIZATIONS - CHILDHOOD & ADULT. Are you able to walk without assistance? .. _____ Are you immunized against: DATE. If no, why?_____ Hepatitis B ..No ..Yes _____. How far?