Social History. Include pertinent findings about use of tobacco products, alcohol, prescription and non-prescription drugs, etc.;
Social History. Smoking Status: Never Smoker□ Former Smoker□ Cigar Smoker□ Current Every day Smoker□ Start Date: Do you drink alcohol? Quit Date: Number of packs per day: Total years Smoking: Yes No If yes, drinks/day How many times in the past year have you had 5 or more drinks in a day for men or 4 or more drinks in a day for women or any adult older than 65? # days Are you pregnant? Yes No If yes, how many weeks? Recreational drugs? Yes No If yes, what drugs? Immunization: Have you had your Influenza Vaccine this year or last year? Yes□ No□ Declined□ If yes, when? Have you had your Pneumonia Vaccine with in the past 5 years? Yes□ No□ Declined□ If yes, when? Any other vaccinations this year? Yes□ No□ What is your occupation? May we leave a detailed message on your phone? Yes No Phone: Pharmacy Information Name: Address if known: Phone: City: Pediatric History (only for minors) Gestational age at birth (in weeks): weeks Birth Weight: lbs oz Maternal illness during pregnancy: Completed by Patient: Signed by patient or responsible party Date:
Social History. What is your current living situation (who lives with you? Please include names and ages of children/parents): Are you experiencing any legal problems (problems types including DUI's, probation officer involvement, pending court dates, arrests, jail time): What do you do for work? What is your satisfaction level with your occupation? Please specify your level of education: What groups, religious affiliations, and supportive networks are you a part of? Please specify those of primary importance: Alcohol & Substance Use Alcohol Use: Yes / No If yes, how much/ how often: Are you currently able to abstain for 72 hours? Nicotine Use: Yes / No If yes, how much/ how often: Are you currently able to abstain for 72 hours? Caffeine Use: Yes / No If yes, how much/ how often: Are you currently able to abstain for 72 hours? Marijuana Use: Yes / No If yes, how much/ how often/how are you ingesting: Are you currently able to abstain for 72 hours?
Social History. How would you describe your support system in the area? • What does a typical day look like for you? What do you enjoy doing? • Do you identify with any religious background or spiritual practice? • Children: ☐ Yes ☐ No Are you a new or expecting parent? ☐ Yes ☐ No Notes on children (i.e. custody, # of dependent children): • Have you had significant periods in which you have had experienced serious problems getting along with people in your life? Note: “Serious problem” means those that endangered the relationship. Also, a “problem” requires contact of some sort, either by telephone or in person In the past 30 days In the past year No Yes No Yes Parents (mother or father) ☐ ☐ ☐ ☐ Siblings ☐ ☐ ☐ ☐ Sexual partner/spouse ☐ ☐ ☐ ☐ Children ☐ ☐ ☐ ☐ Other significant family (specify) ☐ ☐ ☐ ☐ Close friends ☐ ☐ ☐ ☐ Neighbors ☐ ☐ ☐ ☐ Co-workers ☐ ☐ ☐ ☐ Health & Wellbeing • Do you have a primary care physician? If so, who and when did you last see them? _ • When was the last time you saw a doctor/nurse? What was the purpose? How was the experience? • • Number of ER visits in the last year: • Hospital inpatient days in the last year: • Hospital admissions in the last year: • Notes: • Have you ever been a victim of a violent attack during homelessness? ☐ Y ☐ N • Have you ever had any serious head injury/trauma? (Did you lose consciousness? Were you hospitalized? Was surgery required?) _ • Do you currently have any pain or discomfort? Is it chronic or sporadic? • Are you prescribed any medications? ☐ Y ☐ N NAME: DOSE: PURPOSE: DURATION: PRESCRIBER: • Have you been prescribed medications while in jail/prison? ☐ Y ☐ N • How is your sleep? How many hours per day/night? • Do you have vision or dental concerns? • Do you have any of the following ongoing health issues and are you receiving care for this issue? Health issues Have this issue? If yes, receiving care? No Yes No Yes Kidney disease or dialysis ☐ ☐ ☐ ☐ Liver disease or cirrhosis ☐ ☐ ☐ ☐ Heart disease or history of heart attack ☐ ☐ ☐ ☐ HIV+/AIDS ☐ ☐ ☐ ☐ Emphysema ☐ ☐ ☐ ☐ Diabetes ☐ ☐ ☐ ☐ Asthma ☐ ☐ ☐ ☐ Cancer ☐ ☐ ☐ ☐ Hepatitis C ☐ ☐ ☐ ☐ Tuberculosis ☐ ☐ ☐ ☐ Seizure disorder ☐ ☐ ☐ ☐ Stroke ☐ ☐ ☐ ☐ Other ☐ ☐ ☐ ☐ Other ☐ ☐ ☐ ☐ • Do you have any concerns about your mental health? (Onset? When did you first receive tx? Previous diagnoses? Most recent diagnosis?) _ _ • Has anyone ever told you that you have mental illness? _ _ • Overall, how would you describe your mood? _ _ • Have you ever been prescribed medication for m...
Social History. Do you currently smoke cigarettes? ❑ Yes ❑ No How many packs a day? _ ❑ Never smoked Age started? Have you quit smoking cigarettes? When? How many packs a day? _ _ (Congratulations !) Age started? _ Age stopped? Have you chewed tobacco? ❑ Yes ❑ No How many cans per day?_ ❑ Never Age started? _ ❑ Former Age stopped? ❑ Current Do you drink alcoholic beverages? ❑ Former ❑ Yes ❑ No Average drinks per week Have you used “street” drugs? ❑ Yes ❑ No Type Quantity: Age started: _ Age stopped: Have you ever taken steroids? ❑ Yes ❑ No When? _ Reason Family History: ❒ None Medical problems of parents/brothers/sisters, such as cancer, heart disease, arthritis, high blood pressure, diabetes, bleeding problems, trouble with anesthesia, alzheimers, stroke, mental illness:
Social History. Do you currently smoke cigarettes? Yes No How many packs a day? _ Never smoked Age started? Have you quit smoking cigarettes? When? How many packs a day? _ _ (Congratulations !) Age started? _ Age stopped? Have you chewed tobacco? Yes No How many cans per day?_ Never Age started? _ Former Age stopped? Current Do you drink alcoholic beverages? Former Yes No Average drinks per week Have you used “street” drugs? Yes No Type Quantity: Age started: _ Age stopped: Have you ever taken steroids? Yes No When? _ Reason Family History: None Medical problems of parents/brothers/sisters, such as cancer, heart disease, arthritis, high blood pressure, diabetes, bleeding problems, trouble with anesthesia: Relative (mother, father, etc.) Medical Problem Onset Age Drug/Food Allergies (please circle ALL reactions that apply) None DRUGS: Penicillin/Amoxicillin: (itching, rash/hives, breathing difficulty, facial swelling, nausea/GI upset) Sulfa: (itching, rash/hives, breathing difficulty, facial swelling, nausea/GI upset) Iodine: (itching, rash/hives, breathing difficulty, facial swelling, nausea/GI upset) Codeine: (itching, rash/hives, breathing difficulty, facial swelling, nausea/GI upset)
Social History. Any use to Tobacco (type and for how long)? Any use of Alcohol (type and for how long)? Any use of Recreational Drugs (type and for how long)? What type of work do you do? Marital Status: □ Single □ Married □ Divorced □ Widowed PAST MEDICAL HISTORY Do you now or have you ever had: □ Diabetes □ Pneumonia □ Jaundice □ High Blood Pressure □ Pulmonary Embolism □ Stomach or Peptic Ulcer □ High Cholesterol □ Asthma □ HIV/AIDS □ Hypothyroidism □ Emphysema □ Kidney Disease □ Goiter □ Stroke □ Colitis □ Cancer (type) □ Epilepsy (seizures) □ Anemia □ Leukemia □ Angina □ Hepatitis □ Psoriasis □ Heart Problems Other Medical Conditions (Please list):
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Social History. Day care/school grade of the child: Has the child been assessed or diagnosed with any learning disabilities? How would you describe the child’s performance at school?: Please comment on the child’s behaviour and personal experience at school (has it been positive, negative): Does the child have any notable fears, anxieties, or worries? Home Environment Marital status of parents: How many siblings are there at home? How would you describe the emotional climate of the child’s home? Is there any stress in the household? Is the child exposed to smoke?: Y/N Are there pets in the household?: Y/N Type(s): How is the home heated?
Social History. If YES, amount & type: If YES, how often: If YES, type & amount: If YES, type, age, by whom: ____________________________________ ____________________________________ ____________________________________ ____________________________________ Family Medical History (Please include any medical illnesses and cause of death) Father: ____________________________________________________________________________ Mother: ____________________________________________________________________________ Siblings: ____________________________________________________________________________ Others: ____________________________________________________________________________ Medications (please include “over the counter meds” as well) Name: Strength: How Often: MEDICAL RECORD RELEASE FORM Please complete this form and fax to the physician, hospital, or organization from which you are requesting records. This information will then be forwarded directly to our office. I hereby authorize and request medical records are released from: Name of Facility: Address: City/State/Zip: Phone: Fax: To release the following records for the patient: Patient Name: Address: DOB: SSN: Covering the period of treatment: o Complete Files o From / / - / / Records to be released: ¢ Clinical Notes ¢ Radiology Reports ¢ Other Please Specify ¢ Lab Results ¢ Medication Lists ¢ Immunization ¢ Hospitalization Summary Patient’s Name (Please Print) DOB Signature of Patient, Parent, or Legal Guardian Date PATIENT REGISTRATION FORM (Please Print) xxx.xxxxxxxxxxxxxxx.xxx 0000 Xxxxxxxx Xxxxxxx Suite 307 Today's Date: / / Primary Care Doctor: Frisco, Texas 75033 PATIENT INFORMATION Legal First Name Legal Last Name Suffix Gender Address Apt # City State Zip ( ) ( ) - - Primary Phone Cell Phone Social Security # / / Birth Date ¢Married ¢Single ¢Divorced ¢Widowed ¢Other ¢ Email Address (this will be used for appointment reminders and newsletters) Preferred Contact Method ¢Cell ¢Home ¢Email Check for portal access Race Ethnicity Preferred Language ( ) Employeer Name Employeer Phone Number
