• Patient Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date*
     - -
  • Have you been here before?*
  • When
     - -
  • Date of Birth*
     - -

  • Allergies

  • Do you have any allergies?*
  • Reaction type

  • Diabetes

  • Have you ever had high blood sugar or diabetes?*
  • When diagnosed?
     - -
  • Insulin
  • Pills

  • TB Exposure and TB History

  • Have you ever been exposed to TB, had a positive PPD or other TB test??*
  • Exposed to TB?
  • Positive PPD?
  • When?
     - -
  • Is the positive PPD a new conversion (from - to +) within the last 2 years?
  • Did you take INH?
  • Symptoms
  • Have you ever had TB?
  • When diagnosed?
     - -
  • CXR ordered?

  • HIV/AIDS History

  • Do you have HIV infection or AIDS?*
  • When diagnosed?
     - -
  • Date of latest T-cell (CD4) test
     - -
  • History of opportunistic infections

  • Asthma

  • Have you ever had asthma?*
  • Have you ever been intubated for asthma?
  • If yes, when was the intubation?
     - -
  • Have you ever been admitted for asthma?
  • If yes, when was your last asthma admission?
     - -
  • When was your last asthma ER visit?
     - -
  • When was your last asthma attack?
     - -
  • Have you ever taken oral steroids for asthma?
  • If yes, when did you last take oral steroids?
     - -
  • Is your chest tight now?

  • Seizures

  • Have you ever had a seizure?*
  • Are your seizures related to encephalitis, trauma, or other similar causes?
  • Are your seizures drug related?
  • When was your last seizure?
     - -

  • Cardiac Disease

  • Have you ever had cardiac disease?*
  • Have you ever had a heart attack (MI)?
  • If yes, when was the heart attack?
     - -
  • Was the heart attack drug related?
  • Any family history of sudden death under age 55?
  • Current cardiac symptoms
  • Do you have chest pain?
  • Do you have syncope (fainting)?

  • Hypertension

  • Have you ever had hypertension?*
  • When was hypertension diagnosed?
     - -

  • Delivery and OB/GYN

  • Have you recently delivered a baby?*
  • If yes and delivery was within the past 6 weeks, complete the postpartum form.
  • Are you pregnant now?*
  • If pregnant, complete the prenatal form. If recently delivered within the past 6 weeks, complete the postpartum form.
  • LMP
     - -

  • All pregnant women with history of illicit opiate use should be placed on methadone maintenance.

  • STD History

  • Have you ever had syphilis?*
  • History of other STDs
  • When
     - -
  • If yes, advise HIV Ab testing

  • Surgery/Hospitalization

  • History of surgery and/or hospitalization*

  • History of Peptic Ulcer Disease

  • Do you have a history of peptic ulcer disease?*
  • When was the ulcer treated?
     - -

  • Dental

  • Do you have dental problems?*

  • Substance Use

  • Do you use alcohol or drugs habitually?*
  • If yes, which substances have you used?
  • Have you ever considered cutting down on your drinking?
  • Have you ever been annoyed by people asking about your drinking?
  • Have you ever had guilt feelings about your drinking?
  • Have you ever needed a drink as an eye opener?
  • When was the last time you had a drink?
     - -
  • Do you smoke?
  • Are you currently in a methadone program?

  • Mental Health and Safety

  • Any past treatment or hospitalization for a nervous or mental problem?*
  • If yes, when?
     - -
  • Are you taking medication for nerves?*
  • Have you tried to hurt or kill yourself?*
  • If yes, when?
     - -
  • Do you feel like hurting yourself now?*
  • Is there any family history of suicide?*
  • Any history of being disoriented, agitated, hallucinating, or seriously depressed?*

  • Other Medical History

  • Do you have any other medical problems that I did not ask you about?*

  • Family History

  • Medication and Allergy Summaries

  • Additional Information

  • Should be Empty: