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    Patient Profile Adult

    Uploaded by

    Brandon Hubbard
    This document is an adult patient profile for Hope Medical Clinic. It collects identifying and contact information for the patient, including name, date of birth, address, phone numbers, ethnicity, primary language, emergency contact, religion, health insurance status, military service, and healthcare history. It also gathers information on the patient's current medications, allergies, vaccination history, surgeries, health habits, stressors, personal and family health history, and - for women - reproductive health details. The patient or guardian signs the bottom to authorize the collection of this medical history.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Patient Profile Adult

    Uploaded by

    Brandon Hubbard
    116 views2 pages
    This document is an adult patient profile for Hope Medical Clinic. It collects identifying and contact information for the patient, including name, date of birth, address, phone numbers, ethnicity, primary language, emergency contact, religion, health insurance status, military service, and healthcare history. It also gathers information on the patient's current medications, allergies, vaccination history, surgeries, health habits, stressors, personal and family health history, and - for women - reproductive health details. The patient or guardian signs the bottom to authorize the collection of this medical history.

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    This document is an adult patient profile for Hope Medical Clinic. It collects identifying and contact information for the patient, including name, date of birth, address, phone numbers, ethnicity, primary language, emergency contact, religion, health insurance status, military service, and healthcare history. It also gathers information on the patient's current medications, allergies, vaccination history, surgeries, health habits, stressors, personal and family health history, and - for women - reproductive health details. The patient or guardian signs the bottom to authorize the collection of this medical history.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    116 views2 pages

    Patient Profile Adult

    Uploaded by

    Brandon Hubbard
    This document is an adult patient profile for Hope Medical Clinic. It collects identifying and contact information for the patient, including name, date of birth, address, phone numbers, ethnicity, primary language, emergency contact, religion, health insurance status, military service, and healthcare history. It also gathers information on the patient's current medications, allergies, vaccination history, surgeries, health habits, stressors, personal and family health history, and - for women - reproductive health details. The patient or guardian signs the bottom to authorize the collection of this medical history.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Hope Medical Clinic Adult Patient Profile

    Patient First Name


    Print

    M.I.

    Last Name

    Date of Birth
    MM/DD/YYYY

    Todays Date
    MM/DD/YYYY

    Address
    Number Street Lot/Apt City State Zip

    Home Phone -Area Code

    Cell Phone -Area Code

    Work Phone -Area Code

    SSN/Visa/Green Card (circle type); if none, year arrived in USA Native Hawaiian/Pacific Islander Other Married Divorced
    --

    male female

    Ethnicity (mark 1)

    Am Indian/Alaska Native Asian

    Black/African Hispanic/Latino

    Unknown White nonHispanic Widowed

    Primary Language Spoken: Emergency Contact Person


    Name

    Marital Status:

    Never Married

    Relationship to Patient

    Contacts Phone
    Area Code Number Ext

    RELIGION/CHURCH: Do you have Medicaid, Medicare, WHP, or other health coverage? no yes Have you applied for any of these? no yes Are you a veteran? no yes Have you received healthcare elsewhere In the last two years? no yes

    CURRENT MEDICATIONS: List all medications you are (or believe you should be) currently taking:

    ALLERGIES: Check here if you know of no drug allergies, or list below medications and substances you are allergic to or have a bad reaction to: Medication/substance name Describe Reaction Medication/substance name Describe Reaction

    TETANUS: Date of last tetanus shot: _____________________ SURGERIES AND HOSPITALIZATIONS: List the approximate date and reason for each surgery or hospitalization Date Date

    HEALTH HABITS Do you or have you ever smoked or chewed tobacco? no yes Do you use alcohol? no yes Do you use recreational drugs? no yes Are you concerned about HIV/AIDs or STD exposure? no yes

    How many cigarettes a day? What kind?

    At what age did you start?

    When did you quit?

    How often? Per day/week How often? Per day/week Average number of hours you sleep daily:

    What kind?

    Number of meals you eat daily:

    Number of times you exercise weekly:

    Would you like to quit? no yes Would you like to quit? no yes Would you like to quit? no yes Do you wear seatbelts? no yes

    ARE YOU NOW HAVING SERVIOUS SERIOUS PROBLEMS OR STRESS FROM ANY OF THE FOLLOWING? marriage/relationship sexual functioning children physical/psychological abuse job/finances drug/alcohol use housing issues

    Please turn over and complete back


    4/6/06

    PERSONAL HEALTH HISTORY check boxes for conditions in yourself and family members
    Self Mother Father Siblings Childr en Self Mother Father Siblings Childr en

    Alcoholism/substance abuse Arthritis/joint disease Asthma/hay fever/ emphysema/lung disease Blood disorders Bowel/bladder problems Cancer (specify types below) Dental problems Diabetes Heart disease/chest pain/heart attack High blood pressure

    Kidney disease Liver disease/hepatitis Mental Health (depression/anxiety/other) Positive PPD/TB Rheumatic Fever Seizures/epilepsy Sexually transmitted disease Sickle cell anemia Stroke Thyroid

    WOMEN ONLY Indicate number of: Pregnancies ____ no yes Live births _____ Miscarriages _____ Abortions _____

    Have you ever had an abnormal pap? First day of last menstrual period: Birth control method used if applicable:

    Do you perform a monthly breast self-examination? no yes Date of last PAP/vaginal exam: Date of last mammogram:

    _________________________________
    Signature of patient or responsible party (for minor patients, this is parent or legal guardian) ________________________________________ Printed name of responsible party if not patient ________________________________________ Legal relationship of responsible party to patient

    4/6/06

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