Family History. Please indicate with an “X” any significant family medical history or problems. □ asthma □ tuberculosis □ sleep apnea □ COPD or Emphysema □ other lung: _ □ heart attack, myocardial infarction □ congestive heart failure □ irregular heartbeat, arrhythmia □ bleeding problems □ other heart: □ Peripheral neuropathy □ MS or Xxxxxxxxx’x □ other neuro: □ osteoarthritis □ Lupus □ gout □ rheumatoid arthritis □ Other bone & joint: _ □ acid reflux, GERD □ inflammatory bowel disease □ hepatitis - Type □ liver disease □ other GI: □ kidney problems □ dialysis, kidney failure □ diabetes □ psoriasis □ high cholesterol or lipids □ thyroid problems □ sickle cell disease □ any skin ulcer □ Malignant hyperthermia Cancer: any type -- please specify _ _ Other medical problems NOT included above (explain) PATIENT INSURANCE INFORMATION: Please check all insurance coverage you or your spouse has applicable in this case. □ Medicare □ Auto Accident □ Medicaid □ Major Medical □ Blue Cross □ Worker’s Compensation □ Other Insurance Identification Number: Medicare/Medicaid Identification Number: _ Major Medical or Auto Insurance: Date of Accident: Insurance Company Name: Adjuster: Address/Phone: Claim #: Policy #: Effective Date: Patient Initials: Employer Occupation Primary Care Physician: Name & Address: Phone #: LEGAL INFORMATION: Attorney Name & Address: Attorney Phone #: *Person to contact in an emergency (Name and Phone #): Who Referred you to our office?
Family History. Where was the patient born? Where did the patient grow up? City Suburbs Country Please list the patient’s parents, step-parents, siblings, and any other significant family members. Please use additional space on the back if needed. Name Age Relationship Where do they live now? If deceased, age and cause of death Who has the patient lived with throughout their childhood? Mother's occupation: Father's occupation? In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc). Condition Please Circle List Family Member Alcohol/ Substance Abuse Yes / No Anxiety Yes / No Depression Yes / No Domestic Violence Yes / No Sexual Abuse Yes / No Eating Disorders Yes / No Obesity Yes / No Obsessive Compulsive Disorder Yes / No Schizophrenia Yes / No Suicide Attempts Yes / No Other diagnosed mental health condition? Yes / No: Which was?: Guardians’ Marital Status: Primary Guardian #1 (PG#1) / Primary Guardian#2 (PG#2) PG#1 / PG#2 Never Married Domestic Partner Married **If married, how long have you been married, and what is your partner’s name: (PG#1) (PG#2) Separated Divorced -- For how long? Widowed: Please provide your partners name and year deceased: (PG#1 or PG#2?-Circle) *Parent(s) currently in a romantic relationship? Yes -- How long? (PG#1) No (PG#2) What is the patient’s Gender? Preferred pronoun(s)? What is the patient’s Sexual Orientation? Any issues related to gender or sexual orientation that might be relevant to treatment? Physical Health Please list any medications, herbs, or supplements. Be sure to include the condition, as some medications are prescribed for off-label use. Continue on the back if needed, or provide a separate list. If your child has a complicated medical profile, please supply supporting documentation to be able to facilitate a comprehensive understanding of your child’s health. Medication/Supplement Dosage Condition Date Began/Stopped Prescribing provider(s) and contact information: Name: Specialty: Facility: Phone, email, or Fax: How would you rate the patient’s current physical health? Poor Unsatisfactory Satisfactory Good Very Good Please list any specific and significant health problems the patient is currently experiencing: How would the patient rate their current sleeping habits? Poor Unsatisfactory Satisfactory Good Very Good If the patient is having problems, in which phase of sleep are t...
Family History. Pedigree
Family History. Tell me about your family (i.e. child's parents, siblings, grandparents, and other extended family) I verify that the above assessment was discussed with the parent(s) of Signature of Director Date Signed I verify that the director appropriately relayed the information concerning my child's assessment. Signature of Parent Date Signed
Family History. Check any significant immediate family health history: Family History ☐ Diabetes ☐ Heart conditions ☐ Asthma ☐ Epilepsy ☐ Cancer ☐ Mental illness ☐ Gout ☐ Thyroid problems ☐ ☐ ☐ ☐ For Men Only ☐ Frequency of urination ☐ Swollen prostrate ☐ Hesitancy when urinating ☐ Painful urination ☐ Difficulty getting/maintain erection ☐ Benign Prostatic Hyperplasia For Women Only ☐ Used birth control? How long ☐ Hot flashes ☐ Used hormone replacement therapy. How long ☐ Difficultly conceiving ☐ Uterine fibroids ☐ Dramatic mood swings ☐ Uterine cysts ☐ Pounding heart ☐ Endometriosis ☐ Dry vaginal lining ☐ Cervical dysplasia ☐ Osteoporosis ☐ Pelvic pain. How long? ☐ Painful menstrual cramps ☐ Painful intercourse ☐ Absence of menstrual cycle ☐ Genital herpes ☐ Dramatic mood swings around cycle ☐ Vaginal infection (type) ☐ Irregular menstrual cycles ☐ Breast pain, related to cycle? ☐ Headaches (how frequent)? Last? ☐ Breast lumps, change with cycle? ☐ Vaginal discharge (diagnosed)? ☐ Pelvic Inflammatory disease ☐ Vaginal infection (type) ☐ Break through bleeding or spotting between periods ☐ Heavy menstrual bleeding during period Constitutional Intake Form Place a check mark by any symptoms that you currently have or have had in the recent past. UPPER GI RENAL Sometimes nausea in the mornings Standing too quickly makes pulse roar in ears Sometimes nausea in the evenings Standing too quickly causes faintness, dizziness Sometimes excess salivation Wakes up at night to urinate Mouth frequently too dry Frequent flushing or blushing Duodenal ulcer Water retention with change in weather Stomach ulcer Moderate high blood pressure, crave fats Sometimes foul burps Moderate low blood pressure, craves sweets Butterflies in stomach Frequent thirst Seldom eat breakfast Craving for salt Often don’t finish meals Urine always light colored Often eat to calm down Urine usually darker Receding gums Frequent use of alcohol LOWER URINARY TRACT Frequent poor appetite Xxxxxx, demanding hunger Bitter taste in the morning Frequent urination, small amounts Infrequent urination, copious Sometimes dribbles urine afterwards “Dragon breath” in the morning Frequent bladder infections Acid indigestion at night Frequent mouth/cold sores Demanding and sudden need to urinate Mucus in urine Sometimes difficulty swallowing Benign prostatic hypertrophy (males) Indigestion after eating Dull ache after urination LOWER GI REPRODUCTIVE - ALL Stools loose with gas Constipation with gas Frequent constipation Digest...
Family History. 3.1. Parents (Any history of inherited disorders eg. asthma, heart problems, learning difficulties etc):
Family History. Describe and discuss family composition, health of family members including similar disease/disorders in other members of family, the primary caretaker(s) and their role in providing for the DDDS claimant’s medical, emotional, and daily activity needs. Include longitudinal history of relations with parents, family, peers, etc.
Family History. The Division will determine whether an immediate family member is assigned to a Contractor and assign the Member to that Contractor.
Family History. Family Member Living Medical problems or cause of death NO YES Father ❑ ❑ Mother ❑ ❑ Brother ❑ Sister ❑ ❑ ❑ Brother ❑ Sister ❑ ❑ ❑ Brother ❑ Sister ❑ ❑ ❑ IMMUNIZATIONS: Please complete the following immunization table. I understand that while incomplete vaccination will not affect my enrollment to the London campus, I will need to have obtained all required immunizations prior to transfer to the FSU Tallahassee campus and that this information must be verified through the submission of a Student Health History Form certified by a qualified physician. Students born on or after 1/1/57 must provide proof of two MMR (measles, mumps, and rubella) immuniza- tions. The first MMR must have been given on or after 1/1/68 and on or after the first birthday. The second MMR immunization must have been given 28 days or more after the first MMR. Positive titers for measles (Rubeola), German measles (Rubella) and mumps antibodies may be submitted in lieu of proof of two MMR. 1st MMR / / AND 2nd MMR / / month day year month day year NO SINGLE MEASLES, MUMPS OR RUBELLA SHOTS WILL BE ACCEPTED; BOTH IMMUNIZATIONS MUST BE COMBINED MMRs. Proof of the meningococcal and/or Hepatitis B vaccines: Hepatitis B vaccine: dose 1 / / month day year dose 2 / / month day year dose 3 / / month day year Meningococcal vaccine: / / month day year OR Waiver of the meningococcal and/or Hepatitis B vaccines: I recognise the risks of acquiring meningococcal meningitis and Hepatitis B and the benefits of receiving immunizations to reduce those risks. I also understand that I am required to re- ceive these immunizations or actively decline the immunizations. I understand that declining these vaccines now does not mean I may not receive them in the future. I DECLINE receiving the meningococcal vaccine. I DECLINE receiving the Hepatitis B vaccine.
Family History. Information about people living in the household: NAME Date of Birth (Age) Relationship
