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Acknowledgements Form: All Patients Must Complete Chestnut Family Practice Adult Patient History Pediatric Patient History

Chestnut Family Practice Adult Patient History

First Name: *

Last Name: *

Address *

Street, City, State, Zip

Phone: *

Email: *

Birthday *

Race *

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Other

Past Medical History

List all Diagnosed Issues *

Please include the following information (Diagnosis, date of diagnosis)

Past Operations & Procedures: (Age or Date)

Tonsils

Gallbladder

Kidney

Appendix

Stomach

Hernia

Heart

Mastectomy

Cholesterol Screening

Biopsy

Colonoscopy

EKG

Stress Test

Mammogram

OTHER HOSPITALIZATIONS / ACCIDENTS / INJURIES

OB/GYN History

Are you still having a period?

Do you use birth control?

Breast Exam

Pap Smear

Ovaries Removed

Hysterectomy

Tubal Ligation

# of live births

# of miscarriages

# of abortions

# of still births

Current Medications

Prescriptions & over the counter *

Please list name, dose, duration if you are not taking anything please state, NONE.

Allergies & Reactions

List any and all known allergies: *

(Medications, Food, Pollens, etc. and explain your reaction; swelling, rash, stopping breathing, etc) or NONE.

Social History (Habits)

Marital Status *

Do you have children? *

Who do you live with? *

Do you have a living will? *

(Advanced Medical Directive)

Do you have a health care power of attorney? *

Education (Highest Level) *

Occupational Status *

Occupation / Career *

Do you drink alcohol? *

Do you use tobacco products? *

Do you use illegal drugs *

How fequently do you exercise? *

Do you wear a seat belt? *

Do you have dietary restrictions? *

Do you consume caffeine? *

Have you traveled outside the US? *

FAMILY HISTORY

Father

Alive

Deceased

Age

Health Problems:

Mother

Alive

Deceased

Age

Health Problems:

Sister

Alive

Deceased

Age

Health Problems:

Brother

Alive

Deceased

Age

Health Problems:

Children

Alive

Deceased

Age

Health Problems:

Other Family Isues

Systems Review

Cardiovascular

High blood pressure

High cholesterol

Heart attack / Angina

Heart murmur

Swelling feet and ankles

Leg cramps with walking

Mitral valve

Rheumatic fever

Irregular heart beat

Eyes, Ears, Nose & Throat

General

Gastrointestinal

Gynocology

Musculoskeletal

Neurologic

Stroke

Migraine

Headaches

Seizures

Dizziness & Nausea

Fainting

Numbness

Paralysis

Memory loss

Pulmonary

Shortness of breath

Dry cough

Pneumonia

Emphysema

Asthma

Pulmonary Fibrosis

Cystic Fibrosis

Tuberculosis

Psychiatric / Cognitive Issues

Immunizations (Age or Date)

PPD

TB test

Shingles

Flu

Pneumonia

Tetanus

Hepatitis

* Required field