DUBUQUE INTERNAL MEDICINE

HEALTH INFORMATION INVENTORY

Please take a few moments to fill out the following questionnaire. We will use this information as part of our continual efforts to provide you with the best health care. All the information you provide will become part of your medical record and is therefore kept strictly confidential. Please answer these questions to the best of your ability, leaving blank those questions for which you are unsure of the answer.

NAME _________________ DATE OF BIRTH____________
HOME PHONE (__ ) - ________ WORK PHONE (___ ) - ________
TODAY’S DATE ___________  


SURGICAL/HOSPITALIZATION HISTORY (excluding pregnancy; see below):
Reason/Year Reason/Year Reason/Year
_________ _________ _________
_________ _________ _________
_________ _________ _________
_________ _________ _________

PREGNANCY:
Total # of pregnancies___ Number of Live births___ Stillbirth or abortion___

IMMUNIZATION STATUS: Year received Year received
Influenza (most recent) _____ Measles/mumps/rubella
(given together) 		____
Pneumococcal pneumonia _____ Hepatitis B
(approximate date completed)		 ____

Tetanus/diphtheria
most recent booster

_____  


HEALTH HABITS/SOCIAL HISTORY
  YES NO If yes, list how often Your occupationand how many years? (List most recent and/or any occupation where you were exposed to health hazards)
SMOKING o o __________
ALCOHOL o o __________ Any exposure to any chemicals?
oYES oNO
DRUGS o o __________ Chemical name__________

Are you caring for any ill family members at home?o YES o NO
Do you have any disability? ( For example, hearing loss, glasses)LIST:____________

PREVENTIVE HEALTH MEASURES: (List any you have done; use approximate date if you can’t remember)
DATE (of most recent) DATE (of most recent)
EVERYONE: WOMEN:
COLON CANCER SCREENING MAMMOGRAM_____
- Stool hemoccults (blood)_____      PAP SMEAR_____
- Flexible sigmoidoscopy _____     MEN:
Heart disease prevention PROSTATE CANCER SCREENING
- cholesterol measured_____     - PSA _____
- daily aspirin (if ³50y/o)_____     -Rectal exam_____

PAGE 2: HEALTH INFORMATION INVENTORY

Your name_____ Date of Birth_____ Today’s date_____

ALLERGIES/ADVERSE REACTIONS?
Please list any medications, foods or environmental exposures ( for example, bee stings, x-ray dye) that have led to an allergic or adverse reaction (LIST reaction, for example, nausea or rash): _______________________________________________________________

PERSONAL/FAMILY HISTORY
Is there a personal or family history of any of the following diseases?
  Yourself Family
members		 Please list relationship
  Yes No Yes No _______________
Heart attack o o o o _______________
Cancer                          
Colon                  o o o o _______________
Breast                  o o o o _______________
Other________ o o o o _______________
Colon polyps o o o o _______________
Diabetes o o o o _______________
Stroke o o o o _______________
High Blood Pressure o o o o _______________
High Cholesterol o o o o _______________
Liver Disease o o o o _______________
Alcohol/drug abuse o o o o _______________
Psychiatric illness o o o o _______________
Tuberculosis (TB) o o o o _______________
Anesthesia complications o o o o _______________
Other- describe o o o o _______________

ADVANCED DIRECTIVES
In the event that you are unable to express your wishes for certain medical interventions in the future, you should consider a "Living Will" or "Power of Attorney" or both.
  I have one I don’t have one I want more information
LIVING WILL o o o
POWER OF ATTORNEY o o o