Charter Internal Medicine - Patient Health Questionaire

Charter Internal Medicine, LLC

Affiliated with Johns Hopkins Medicine

10700 Charter Drive, Suite 200

Columbia, Maryland 21044

Phone: (410) 910-2300 / Fax: (410) 910-2310

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Patient Health History Questionnaire

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Name

________________________________

Date of Birth

__________

Yes ___

No ___

Do you have any allergies or have you had any reactions to any medicine?

Yes:

___

No:

___

Please list medicines and reactions:

____________________________________________

______________________________________________________________________________

Do you have a living will?

Yes

___

Please list all medicines you are currently taking:

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Name of Medicine	Amount (Dose)	How Long?	Doctor's Name	For What Reason?

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Immunization Status:
Have you had the influenza or pneumovaz vaccine?	Yes	___	No	___	When?	_____

When was your last tetanus vaccine/booster?	_____________________________
Other vaccines? If so, what vaccine and when?	_____________________________

Medical History Review

Have you had or do you currently have?	Do you have a	Relationship?
	family history of?

Have

Had

Never

Diabetes (sugar)

Yes

___________

Have

Had

Never

Glaucoma

Yes

___________

Have

Had

Never

Bleeding Disorder or blood disease

Yes

___________

Have

Had

Never

Asthma or Hay Fever

Yes

___________

Have

Had

Never

High blood pressure or stroke

Yes

___________

Have

Had

Never

Heart attacks or chest pain

Yes

___________

Have

Had

Never

Seizures, convulsions, blackouts

Yes

___________

Have

Had

Never

Depression, suicide, mental illness

Yes

___________

Have

Had

Never

Cancer: Type _____________________

Yes

___________

Have

Had

Never

Chronic ear infections or drainage

Have

Had

Never

Ulcers, stomach or intestinal bleeding

Have

Had

Never

Weight problem: Over ____ Under ____

Have

Had

Never

Heart murmur / Rheumatic fever

Have

Had

Never

Treatment with cortisone

Have

Had

Never

Angry, emotional or abusive exchanges with your spouse?

Have

Had

Never

Children with special problems or difficulty getting along with family or friends?




Do you have a family history of: Drug Abuse Yes ___ No ___
	Alcohol	Yes ___	No ___

Patient Health History Questionnaire continued. . .

Patient's Name (Print): _________________________________________________________________

Past Hospitalizations/Surgery? Yes ___ No ___ If yes, please list ____________________________

_________________________________________________________________________________

FEMALES ONLY

Menstruation: Age of Onset _____

Regular ____ Irregular ____

Flow: Heavy ____ Moderate ____ Light ____

Pain cramps with menstrual flow? Yes ___ No ___

Bleeding after sex: Yes ___ No ___

No. of pregnancies: _____

No. of live births: ____ No of miscarriages: ____

Birth Control Method:______________________

Brand of Birth Control Pills: ________________

Are you currently breast-feeding? Yes __ No __

Do you practice breast self-exam? Yes __ No __

Flushing / Menopause? Yes __ No __

MALES ONLY

Do you perform Testicular self-exam?

Yes ___No ___

Is there a history of impotence?

Yes ___ No ___

Do you have urethral discharge?

Yes ___ No ___

LIFESTYLE

Tobacco Use? Yes __ No __ If yes, number of pack per day ____ for ____ years

Are you an ex-smoker? Yes __ No __, if YES, how many packs per day did you smoke? ____

Alcohol user? Yes __ No __, if YES, type and amount per day? ____________

Coffee user? Yes __ No __, if YES, number of cups per day? ______________

Do you have a regular exercise program? Yes __ No __

Do you wear a seatbelt? Yes __ No __

Do you use "street drugs"? Yes __ No __

PREVENTION AND SURVEILLANCE: When was the last time you:

Had a bowel movement test using a cardboard slide (hemoccult) for hidden blood? ________________

Had a digital rectal exam (doctor uses his/her finger to look for tumors in the rectum? _______________

Had a sigmoidoscopy (instrument place in the rectum to look for tumors? _______________

Had an eye exam with glaucoma check? _______________ Had a dental exam? _______________

If you ever used tobacco, had a doctor feel inside your mouth? _______________

If female: Had a mammogram _______________ Had a Pap test? _______________

Discussed breast self-exam with a doctor? _______________

Had a breast exam by a doctor? _______________

If male: Had a prostate check? _______________