MARK W. HINMAN MD, LLC
1350 Tulip, Longmont, CO 80501

FEMALE PATIENT WORKSHEET FOR PERIODIC PHYSICAL: Please fill these forms in as best you can prior to coming in for your Physical. Doing so will make for more efficient use of your time in the office, as well as helping ensure that you don't miss giving, or I miss requesting, information that should be considered. Please continue on back where more room is needed.

IDENTIFYING DATA:

Name_________________________

Birth date______________________

Date your physical is scheduled_________________

CURRENT HEALTH PROBLEMS AND SPECIAL CONCERNS: Please list any symptoms or concerns which you feel may be a health problem. Use back of sheet if needed. Where you can, list the symptom and:

(a) When it started.
(b) Whether steady or intermittent.
(c) Whether has any relation to time of day, meals, or any other activity or event.
(d) What makes it better.
(e) What makes it worse.
(f) What other symptoms occur with it.
(g) What it feels like to you.
(h) What you are most concerned about regarding it.

Symptom

Description
   
   
   
   
   
   
   
   
   
   
   

PAST HISTORY:

-Please list all events which have ever involved hospital admissions or major illnesses, injuries, or surgery:

Hospital Admissions, Major Illnesses, Injuries, or Surgeries
 
 
 
 
 
 

 

-Please list occasions where you have been treated for high blood pressure, vein clots, passing out, asthma, heart problems, kidney problems, hepatitis, ulcers, bleeding problems, or significantly abnormal tests:

Disease

No

Yes

Where and When Treated

High Blood Pressure

      

Vein Clots

      

Passing Out

      

Asthma

      

Heart Problems

      

Kidney Problems

      

Hepatitis

      

Ulcers

      

Bleeding Problems

      

Significantly Abnormal Tests

      

MEDICATION HISTORY:

-Please list: medication, dose, when taken, and year started for all regularly taken medications including over the counter medications and vitamins:

Medication

Dosage

When Taken

Year Started
       
       
       
       
       
       
       
       
       
       

ALLERGIES: Please list medications, and reaction, for medications to which you have an allergy or to which you have undesirable side effects:

Medication

Reaction

Date
     
     
     
     

 

FAMILY HISTORY: Please list below the following information.
-Number of brothers and sisters:
-Age at death and cause of death for parents, grandparents, and brothers or sisters:

Relative

Age at Death

Cause of Death

Relative

Age at Death

Cause of Death

Father

    

Brother

    

Mother

    

Brother

    

MGM

    

Brother

    

MGF

    

Sister

    

PGM

    

Sister

    

PGF

    

Sister

    

MGM = Maternal Grandmother MGF = Maternal Grandfather
PGM = Paternal Grandmother PGF = Paternal Grandfather
Family members (parents, grandparents, uncles, aunts, brothers, sisters), and condition they had, for any of the following or for other conditions seeming to run in the family:

Disease

No

Yes

If Yes, Which Family Members

Heart Attacks

      

Stroke

      

Diabetes

      

Cholesterol Problems

      

High Blood Pressure

      

Asthma

      

Bleeding Disorders

      

Kidney Disease

      

Epilepsy

      

Migraine

      

Neuromuscular Disease

      

Mental Disease

      

Osteoporosis

      

Cancer

      

Blood Diseases

      

Genetic or Hereditary

      

Other Diseases

      

 

SOCIAL HISTORY: Please list:

Birthplace:

Nationality:

Religion:

Place of Work and Job Description:

Others Living at Home:

Major Interests:

Any Foreign Residence:

Amount of Daily Alcohol:

Amount Daily Tobacco:

Amount Daily Caffeine:

Other Substance Usage:

Meals/Day:

# vegetables/day:

# fruit/day:

# of between meal items/day:

Times/week of exercise:

# minutes/exercise:

Exercise Activities:

HEALTH MAINTENANCE: Please list date (and any unfavorable outcomes) for last:

General Physical

EKG

Sigmoidoscopy

General Blood Screens

Other Routine Tests or Procedures

DT (tetanus shot)

Measle Shot

Pneumonia Shot

Flu Shot

PAP Smear

Mammogram

 

ADVANCE DIRECTIVES:
-Have you made a living will or medical power of attorney?
-If not, do you have any express wishes on life support if you should develop a catastrophic medical condition?

 

SYSTEM REVIEW: Please place a check mark in the yes column for any of the following conditions or situations where you have experienced symptoms or occurrences, or where you have questions. Explain all yes symptoms at the end:

GENERAL

Yes

No

  
     

Have you had unexplained or significant weight change?
     

Have you had fever, chills, night sweats or temperature intolerance?
     

Have you had unexplained pain, bleeding, weakness, or tiredness?
     

Have you had any sort of spells or attacks?

DERMATOLOGIC

    

Have you had any lumps or skin lesions that are changing or are of concern to you?
     

Have you had unusual or troublesome itching, rashes, or pigmentation changes?

HEENT

    

Have you had any recent change in vision or visual symptoms?
     

Do you have any trouble with hearing, ringing, or pain in the ears?
     

Any trouble chewing or swallowing?
     

Any mouth or tongue soreness or lesions?

RESPIRATORY

    

Have you had a cough which is changing or is productive of colored material or blood?
     

Have you had wheezing or other breathing difficulties?

CARDIOVASCULAR

    

Have you had any pain or distress that you feel may be from your heart?
     

Do you get unusual shortness of breath or fatigue with ordinary activities, such that you need to stop for rest or avoid them?
     

Do you have problems with swelling or palpitations?
     

Does anything else lead you to feel you have heart or circulation problems?

GASTROINTESTINAL

    

Have you had any unusual or troublesome problems with swallowing, digestion, appetite loss, or abdominal pain or distress?
     

Have you had problems or changes with bowel habits or bowel movements?
     

Have you noticed any blood or black tarry bowel movements?

UROLOGIC

Yes

No

Have you had any problems with starting, stopping, or frequency of urination or any pain or distress with urination?
     

Have you had any blood in the urine or any other abnormalities or significant changes in urine or urination?

GENITAL

    

Have you had problems with pain, irregular or heavy bleeding, or other problems with menstrual periods?
     

Have you had lumps or other breast problems?
     

Have you had problems with premenstrual tension?
     

Have you had hot flashes, pelvic pain, or any sexual problems?
     

Have you had more than 1 sexual partner in the last year?

MUSCULOSKELETAL

    

Have you had unusual or troublesome joint swelling or stiffness?
     

Have you had to limit activities due to muscle, joint, or bone pain?

NEUROLOGIC

    

Have you had unusual or severe headaches?
     

Have you had any problems with memory or concentration?
     

Have you had problems with balance or coordination or with doing activities with which you normally do not have problems?
     

Have you had problems with numbness, vision, taste, smell, or speech?

BEHAVIORAL

    

Do you feel, or have you been told, that you need to cut down on alcohol consumption?
     

Are there other habits or problems that you feel, or that you have been told, that you need to better control?
     

Do you feel your life situation is hopeless?
     

Are you having unusual or overwhelming stress or depression?
     

Have you stopped doing any activities because of fears, panic, or feelings of inadequacy, hopelessness, or general disinterest?
     

Have you had sleep problems?
     

Have you had any personality changes?
     

Have you had other problems causing you to feel you might benefit by some type of psychiatric help?

 

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