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 ..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: _____.

2 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 ..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.

3 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:_____. _____. _____. 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.

4 No ..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 ..No ..Yes _____ _____ Have you ever had: WHEN. Asthma ..No ..Yes _____ _____ Rheumatic fever or heart ..Yes _____.

5 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 ..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.

6 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. 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.

7 _____ Take laxatives frequently ..No ..Yes _____. Loss of _____ Recent change in bowel action ..No ..Yes _____. Dizzy or fainting _____ Recent prolonged ..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?..No.

8 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? _____ MMR (Measles, Mumps, Rubella) ..No ..Yes _____. Do you have difficulty going up stairs? .. _____ Tetanus ..No ..Yes _____. Can you prepare your own meals? .. _____.

9 Yes _____. Influenza ..No ..Yes _____. GENITOURINARY: Have you ever had: WHEN Date of last TB skin test _____. Kidney disease or _____ Results (If known) Positive _____ Negative _____. Venereal disease .. _____ Date of last chest x-ray _____. Difficulty in urination .. _____ Was it normal ..No ..Yes _____. Frequent _____. Burning or pain with urination .. _____ HAVE YOU HAD THE FOLLOWING: DATE. Leakage of urine .. _____ Electrocardiogram (EKG) ..No ..Yes _____. Blood in urine .. _____ Stomach x-ray ..No ..Yes _____. Number or times you arise to urinate during sleep hours _____ Kidney x-ray ..No ..Yes _____. Bowel x-ray ..No ..Yes _____. ENDOCRINE: Of what _____. Have you ever had problems with: WHEN Nuclear ..Yes _____. Thyroid .. _____ Of what _____.

10 Diabetes .. _____ X-ray/Radiation treatments ..No ..Yes _____. Extreme thirst .. _____ For what _____. Electroencephalogram (EEG) ..No ..Yes _____. SKIN: Have you ever had: WHEN For what _____. Skin diseases .. _____ Other _____. GYNECOLOGICAL (Women only): Do you have someone locally who can help you if needed? .. Menstrual history - age of onset_____ Are you able to be involved with social functions? .. Cycle _____ (days from start to start) If not, why?_____. Usual duration _____ days Are there cultural issues that affect your health care? .. Regular _____ Irregular _____ If yes, please explain _____. First day of your last period _____ (date) Are there medical treatment limitations based on your faith? .. Birth control method _____ Will you accept blood transfusions?