Patient Health History Form

Your Name Your Date of Birth

Today’s Date

Taking care of your health is important to us and we take this responsibility seriously! CentraCare Health System has recently transitioned
your paper medical chart to an electronic version. Our number one priority in this project has been improved patient care. It is essential that
this electronic medical record have all the information vital to your care and to accomplish this objective we are requesting that you complete
the following information. Once your past medical and family history has been entered into the electronic record, this information need only to
be reviewed and updated in the future. Please provide your best estimate if you are unable to remember specific dates or details.
Allergies Staff: Enter into Allergy Activity
Do you have any allergies to medications or other substances?

Medication or Substance What kind of reaction?

Medications Staff: Enter into Medication Documentation

List any prescription or over the counter medications you take on a regular basis. Include supplements, herbal or homeopathic medications.

Pill
Start Taking
Current Medication(s) strength, if Dose Who prescribed this?
Date Now?
known

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Past Medical History Staff: Enter into History Activity or History Template on the navigator

Have you been diagnosed with any of the following health problems (past or present):
Cancer History
Yes No Yes No
Bladder Cancer អ អ Multiple Myeloma អ អ
Brain Cancer អ អ Non-Hodgkin Lymphoma អ អ
Breast Cancer អ អ Oral Cavity Cancer អ អ
Colon Cancer អ អ Ovarian Cancer អ អ
Esophageal Cancer អ អ Prostate Cancer អ អ
Hodgkin Lymphoma អ អ Rectal Cancer អ អ
Kidney Cancer អ អ Stomach Cancer អ អ
Leukemia អ អ Testicular Cancer អ អ
Liver Cancer អ អ Thyroid Cancer អ អ
Lung Cancer អ អ Uterine Cancer អ អ
Melanoma អ អ អ អ

Other Medical History:

Previous Cancer Treatments

Yes No Yes No
Alternative Medicine Treatment អ អ Chemotherapy អ អ
Bone Marrow Transplant អ អ Radiation Therapy អ អ

Other Medical History:

Other Medical History

Yes No Yes No
Alzheimer’s Disease អ អ HIV/AIDS អ អ
Anemia or Low Hemoglobin អ អ Inflammatory Bowel Disease អ អ
Anxiety អ អ Irregular/Fast Heart Rate អ អ
Asthma អ អ Heart Attack អ អ
Bladder or Urinary Infections អ អ Kidney Disease អ អ
Blood Clots or Deep Vein Thrombosis អ អ Kidney Stones អ អ
Chest Pain (heart related) អ អ Liver Disease អ អ
Chronic Lung Disease អ អ Lupus អ អ
Colitis អ អ Lyme Disease អ អ
Congestive Heart Failure អ អ Multiple Sclerosis អ អ
COPD អ អ Osteoporosis អ អ
Crohn’s Disease អ អ Pancreatitis អ អ
Depression អ អ Parkinson’s Disease អ អ
Diabetes អ អ Rheumatoid Arthritis អ អ
Gallbladder Problems អ អ Schlerodema អ អ
Heart Attack អ អ Seizures or Epilepsy អ អ
Heart Murmur អ អ Serious Mental Health Problem អ អ
Hiatal Hernia អ អ Thyroid Problems អ អ
High Blood Pressure អ អ Tuberculosis អ អ
History of Blood Transfusion អ អ Ulcers អ អ

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Surgical History Staff: Enter in Surgical History
What kind of surgery have you had, if any? អ None

Date of Where was the surgery

Procedure or Surgery Any complications?
procedure done?

Any problems with anesthesia? អ No អ Yes, please explain:

អ Any pacemakers or internal device
Family History Staff: Enter in History Activity or within the History Template of the Visit Navigator

Anesthesia Complications

Blood/Bleeding Disorders
Use a check mark to indicate a family
Negative/No History Of

history or any of the following health

Alcohol/Drug Problem

problems. Also note the relationship of

affected individual to you. Additional

Genetic Disease
Ovarian Cancer

Kidney Disease
Cancer (other)
Breast Cancer

Heart Disease

Lipid Problem

Mental Health
family members, put on back page.
Colon Cancer

Hypertension
Diabetes
អ Adopted, no medical history for
Arthritis

Obesity

Thyroid
Asthma

Stroke

Other
biological family members

Relationship Name Status

Parent Mother អ Living
អ Deceased
Cause:

Age of Cancer
Diagnosis

Parent Father អ Living

អ Deceased
Cause:

Age of Cancer
Diagnosis

Grandparent Mom’s Mother អ Living

អ Deceased
Cause:

Age of Cancer
Diagnosis

Grandparent Mom’s Father អ Living

អ Deceased
Cause:

Age of Cancer
Diagnosis

Grandparent Dad’s Mother អ Living

អ Deceased
Cause:

Age of Cancer
Diagnosis

Grandparent Dad’s Father អ Living

អ Deceased
Cause:

Age of Cancer
Diagnosis

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 Anesthesia Complications

Blood/Bleeding Disorders
Use a check mark to indicate a family

Negative/No History Of
history or any of the following health

Alcohol/Drug Problem
problems. Also note the relationship of
affected individual to you. Additional

Genetic Disease
Ovarian Cancer

Kidney Disease
Cancer (other)
Breast Cancer

Heart Disease

Lipid Problem

Mental Health
family members, put on back page.

Colon Cancer

Hypertension
Diabetes
អ Adopted, no medical history for

Arthritis

Obesity

Thyroid
Asthma

Stroke

Other
biological family members

Relationship Name Status

Sibling អ Bro អ Sis អ Living
អ Deceased
Cause:

Age of Cancer
Diagnosis

Sibling អ Bro អ Sis អ Living

អ Deceased
Cause:

Age of Cancer
Diagnosis

Sibling អ Bro អ Sis អ Living

អ Deceased
Cause:

Age of Cancer
Diagnosis

Children អ Son អ Dau អ Living

អ Deceased
Cause:

Age of Cancer
Diagnosis

Children អ Son អ Dau អ Living

អ Deceased
Cause:

Age of Cancer
Diagnosis

Children អ Son អ Dau អ Living

អ Deceased
Cause:

Age of Cancer
Diagnosis

Do you have any hereditary diseases in your family not documented already above? អ No អ Yes, please describe:

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 Health Habits & Personal Safety Staff: Enter in History Activity or within the History Template of the Visit Navigator
Tobacco: Are you exposed to second hand smoke on a regular basis? អ No អ Yes, at home អ Yes, work
Do you use tobacco products? អ Yes អ Never អ Quit, date _______________
If yes, what type(s)? អ Cigarettes អ Cigars អ Chew អ Snuff អ Pipe
If cigarettes, how many packs per day? អ <25 អ 0.5 អ 1.0 អ 1.5 អ 2.0 អ ______
If using other types of tobacco, how much per day?
Are you interested in quitting? អ Yes អ Not interested
Alcohol: Alcohol use per week:
_______ Can(s) of beer _______ Drinks with 0.5 oz of alcohol _______ Glass(es) of wine _______ Shot(s)
អ I do not drink alcohol អ Quit, date _______________
Is your alcohol use a concern for you or others? អ No អ Yes
Drugs: Do you currently use recreational or street drugs? អ No អ Yes
If so, what kind?
How many times per week do you use? ________
Sexuality Are you sexually active? អ No អ Yes
Sexual partner(s) are អ Male អ Female
Birth Control & Infection Protection: អ None needed អ What kind?
Do you have any concerns about your sex life? អ No អ Yes
Advanced Directive
Do you have a health care directive? អ No អ Yes
Social Documentation
Marriage Status: Number of Children:
Partner Information: Spouse or Partner’s Name
Occupation & Education: Your Occupation: Your Years of education:
Have you been exposed to: Asbestos: អ No អ Yes Involuntary Smoke: អ No អ Yes Wood Dust: អ No អ Yes
Benzene: អ No អ Yes Coal Tar: អ No អ Yes Randon: អ No អ Yes
Other environmental exposure: អ No អ Yes
For Women – Obstetrical History
How many pregnancies have you had? ________ Miscarriages or pregnancy losses? ________ Premature deliveries? ________
What complications during pregnancy or childbirth, if any?
*Age at first period? ________ *Age at first pregnancy: ________ *Age at last pregnancy: ________
*Age at Menopause: ________ *Breastfeeding duration: ________
*Hormonal contraceptive use duration: ________ *Hormone replacement use duration: ________ *Hot Flashes: ________
Date of last Menses: When/how long
Preventive Health Screening
Have you had any of the following tests done outside of CentraCare Health System? If so, please list dates.
Colonoscopy ____________________ Bone density (DXA scan) ____________________
For women: Mammogram ____________________ Pap smear ____________________ Pelvic exam ____________________
For men: PSA (prostate specific antigen) ____________________
Genetics
Have you ever had genetic testing/counseling? អ Yes អ No
If yes, describe:
Immunizations Staff: Enter into Immunization Activity
Most Recent Immunization Dates, if known: Hepatitis A ____________ Pneumovax ____________ Influenza ____________
Hepatitis B ____________ Varicella (Chickenpox) ____________ Tetanus (TD) ____________

Spouse/Significant Other:
Does you spouse/significant other live with you? អ No អ Yes
Health of spouse/significant other?
Is this person willing/able to help you? អ No អ Yes
Does this person depend on you for help? អ No អ Yes
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Patient Name:
REVIEW of SYSTEMS: Please  all of the items that currently apply to you.
GENERAL RESPIRATORY BREAST
Normal Weight: អ Shortness of Breath អ Pain in Breast
អ Recent Weight Loss អ Difficulty Breathing អ Lump or Mass in Breast or Armpit
Amount: អ Coughing អ Discharge or Bleeding from Nipple
អ Recent Weight Gain អ Dry Cough អ Change in Nipple
Amount: អ Coughing Up Sputum អ Nipple Inversion
អ Loss of Appetite អ Coughing Up Blood អ Lump
អ Fatigue GASTROINTESTINAL (GI) អ Surgery to Breast
អ Weakness អ Heartburn អ Change in Size, Shape or Contour
អ Fevers អ Nausea/Upset Stomach of Breast
អ Chills អ Abdominal Pain Bra Size:
អ Night Sweats អ Vomiting NEUROLOGICAL
អ Sleep Problems អ Jaundice អ Headaches
EYES អ Change in Bowel Habits អ Tremors
អ Glasses How Long? អ Memory Loss
អ Contact Lenses អ Constipation អ Difficulty Finding Words
អ Glaucoma អ Diarrhea អ Difficulty Writing
អ Cataracts អ Blood in Stool អ Difficulty Thinking Clearly
អ Double Vision អ Hemorrhoids/Fissures អ Numbness or Tingling
អ Change in Vision GENITOURINARY (GU) អ Dizziness
អ Other Vision Problems អ Difficulty Urinating អ Loss of Consciousness
EARS/NOSE/THROAT អ Frequent Urination អ Seizures
អ Loss of Hearing អ Painful Urination អ Coordination
អ Hearing Aid អ Up at Night to Pass Urine អ Unsteady Gait
អ Ringing in Ears អ Blood in Urine PSYCHIATRIC
អ Other Ear Problems អ Color Change in Urine អ Nervousness
អ Nose Bleed អ Sexual Difficulties អ Anxiety
អ Dentures MUSCULOSKELETAL អ Depression
អ Dental Problems អ Leg Cramps អ Change in Personality
អ Frequent Sore Throats អ Painful Muscles អ Relationship Problems
អ Hoarseness អ Painful Joints ENDOCRINE
អ Difficulty Swallowing អ Physical Disabilities អ Excessive Thirst
អ Dry Mouth អ Gout អ Excessive Urination
អ Loss of Taste អ Artificial Joints អ Thyroid Problems
អ Neck Stiffness អ Prosthesis MEN ONLY
អ Neck Pain or Swelling Where? អ Currently Sexually Active
CARDIOVASCULAR SKIN អ Impotence
អ Pacemaker អ Itching អ Difficulty with Erections
អ Chest Pain អ Rash អ Penile Discharge
អ Irregular Heartbeat អ Blotchy អ Testicular Mass
អ Palpitations អ Scaling អ Testicular Pain
អ Hypertension អ Sores
អ Sleep Sitting or Propped Up អ Color Changes
អ Short Breath When Lying Down អ Growths (mole changes)
អ Fainting Spells HEMATOLOGIC & LYMPHATIC
អ Leg Pain While Walking អ Swollen Lymph Glands
អ Swelling in Feet អ Excessive Bruising
អ Varicose Veins អ Excessive Bleeding
អ Oxygen Use at Home

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