Bilingual Physical Form Questionnaire

[Guest guest]

Anyone have a Physical Exam form that is in english and spanish?

Something similar to the one below, perhaps.

Thanks

lockek@...

Locke, MD

Adult History Form - Female

Please list SPECIAL PROBLEMS you would like evaluated today in order of significance:

1.

2.

3.

4 .

MEDICATION ALLERGIES: (such as penicillin)

What happens when you take that medicine?

OTHER ALLERGIES: (such as bees/wasps, foods, latex, etc)

What happens when you are exposed:

MEDICATIONS: Prescription and Non-Prescription (including aspirin, vitamins, birth control, herbs, supplements, etc.)

PAST MEDICAL HISTORY

Please describe and give dates of any illnesses, injuries, hospitalizations, and surgeries:

IMMUNIZATIONS

Hepatitis B ___Yes ___ No

Date:

Hepatitis A ___Yes ___ No

Date:

Tetanus ___Yes ___ No

Date:

Influenza (flu) ___Yes ___ No

Date:

Have you had Chickenpox? ___Yes ___ No

Date:

MMR (Measles, Mumps, Rubella) ___Yes ___ No

Date:

“Pneumonia Shot” ___Yes ___ No

Date:

Have you ever had a test for Tuberculosis? ___Yes ___ No if yes (circle one) : Positive / Negative Date:

Have you ever had a blood transfusion? ___Yes ___ No if yes: Dates:

Adult History Form - Female

FAMILY HISTORY

Please check any family members who have the following health problems.

Father

Mother

Brother

Sister

Grandparent

Other

Diabetes

Glaucoma

Cancer (List type)

Heart attack

Angina

Stroke

High blood pressure

High cholesterol

Alcoholism

Drug Abuse

Depression

Mental Illness

Suicide

Other health problems

SOCIAL HISTORY

Spouse's Name:

Spouse's Occupation:

Ages of Children:

# of People in Household:

Your Occupation:

Place Employed:

Level of Education:

Hobbies:

Recent Significant Changes in Your Life?

___Yes ___ No

Financial Hardships?

___Yes ___ No

Have Special Stresses in Your Life?

___Yes ___ No

I am NOT happy with (circle those that apply) à

Myself My Health My Work

My Partner My Life

à Because violence is so common in many people's lives, I've begun to ask all my patients about it.

Have You Been In An Abusive Relationship?

___Yes ___ No

Does your partner ever hit you, hurt you, or threaten you in any way?

___Yes ___ No

Has your partner ever forced you to have sex when you didn't want to?

___Yes ___ No

Are you ever frightened of your partner?

___Yes ___ No

Has anyone ever hit you, hurt you, or threatened you in the past?

___Yes ___ No

Adult History Form - Female

Tobacco Use:

Have you ever used tobacco products regularly? ___Yes ___ No à if yes, please continue below:

Year Started

Circle those used

Amount

Year Quit

Still Use?

__________

__________

__________

__________

CigarettesCigars

Smokeless/Chew

Pipe

_____pack/day

_____#/week

_____Dips/day

_____ #/week

__________

__________

__________

__________

_____Yes _____ No

_____Yes _____ No

_____Yes _____ No

_____Yes _____ No

Are you exposed to passive smoke? _____Yes _____ No

Do you use other drugs or substances that could affect your health? _____Yes _____ No

HIV/AIDS Risk:

Certain activities and medical problems can increase your risk for becoming infected with the HIV/AIDS virus.

Please review the list of risks below:

Have ever shared injection drug needles and syringes or "works."

Have ever had sex without a condom with someone who had HIV/AIDS.

Have ever had a sexually transmitted disease, like chlamydia or gonorrhea.

Received a blood transfusion or a blood clotting factor between 1978 and 1985.

· Have ever had sex with someone who has done any of those things.

Do any of these activities or problems apply to you? _____Yes _____ No

Caffeine Intake: On average, I drink caffeinated drinks this many times per day (circle) à 0 1 2 3 4 5+

Heart Disease Risk Factor:

Do you have a Family History of:

Heart Attack in a sister or mother before the age of 65 years of age? _____Yes _____ No

Heart Attack in a brother or father before the age of 55 years of age? _____Yes _____ No

Alcohol Use: Check the beverages you regularly consume and list the amount you drink per DAY on average:

_____ Beer:_____ Wine:_____ Hard liquor:_____ Other:

0 Less than 1 1 2 3 4 More than 4

0 Less than 1 1 2 3 4 More than 4

0 Less than 1 1 2 3 4 More than 4

0 Less than 1 1 2 3 4 More than 4

Drugs and Alcohol can sometimes effect your health and the medications you take. Please answer the following:

Yes No

Have you ever felt you should cut down your drinking?

Yes No

Have people annoyed you by criticizing your drinking?

Yes No

Have you ever felt bad or guilty about your drinking?

Yes No

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

Yes No

In the last year, have you drunk or used non-prescription drugs to deal with your feelings, stress, or frustration?

Yes No

As a result of your drinking or drug use, did anything happen in the last year that you wish didn’t happen?

Adult History Form - Female

ORGAN DONATION: Do you want to be an Organ Donor? _____Yes _____ No _____ Don’t Know

ADVANCED DIRECTIVES: Do you have an advanced directive or living will: _____Yes _____ No

CURRENT HEALTH PRACTICES

Exercise, Safety, and Food can all play a role in your health.

Please answer the following questions to see what areas might put you at risk.

Do you exercise regularly? _____Yes _____ No If Yes à Times per Week: _____

Type of exercise:

How often do you wear your seat belt?: _____100% of the time _____75% _____50% _____25% _____Never

How often are you exposed to the sun? _____Frequently _____Occasionally _____Rarely _____A lot in the past

Please indicate the date of any of the following tests:

Colonoscopy (large intestine cancer screening test):

Mammogram (screens for breast cancer):

Pap Smear (screens for cervical cancer):

_____Never had one Date: __________

_____Never had one Date: __________

_____Never had one Date: __________

How many meals do you eat per day? Snacks per day?

How many meals do you eat out per week?

Amount and type of dairy products you consume per day:

List any nutrition or diet concerns you would like help with:

If you are on a special diet, please explain:

Are you happy with your weight? _____Yes _____ No

Do you have regular Dental check-ups? _____Yes _____ No How often do you brush/day _____ floss_____

___Yes ___ No Do you ride a motorcycle?

___Yes ___ No Bicycle?___Yes ___ No Ski/Snowboard?

___Yes ___ No Skateboard?

If yes, do you wear a helmet? ___Yes ___ No

Have you been exposed to any Toxic Substances, such as asbestos, DES, radiation, chemicals?

___Yes ___ No à if yes, please explain:

Do you have a smoke detector in the home: ___Yes ___ No

When was it last checked?

Adult History Form - Female

REVIEW OF SYSTEMS: Check the Yes or No column for those symptoms you currently have significant problems with.

Yes

No

General

Yes

No

Gastroenterology

Yes

No

Dermatology

Fever

Nausea

Rash

Chills

Vomiting

Itching

Sweats

Diarrhea

Dryness

Poor appetite

Constipation

Suspicious skin lesions

Fatigue

Change in bowel habits

Weakness

Abdominal pain

Yes

No

Neurology

Just don’t feel well

Black or tar-like stools

Paralysis

Weight loss

Bloody stools

Unusual sensations

Sleep problems

Jaundice (skin turned yellow)

Seizures

Gas/Bloating

Tremors

Yes

No

Eyes

Indigestion/Heartburn

Vertigo / Dizziness

Blurring of your vision

Difficulty swallowing

Temporary blindness

Double vision

Pain with swallowing

Frequent falls

Irritation of the eyes

Frequent headaches

Discharge of the eyes

Yes

No

Genitourinary

Difficulty walking

Vision loss or change

Vaginal discharge

Eye pain

Incontinence / Leaking urine

Yes

No

Psychiatric

Eyes are sensitive to light

Painful urination

Depression

Blood in the urine

Anxiety

Yes

No

Ears, Nose, Throat

Frequent urination

Memory loss

Earache

Missed periods

Suicide thoughts

Ear discharge

Heavy periods

Hallucinations

Tinnitus / Ringing in Ears

Unusual vaginal bleeding

Paranoia

Decreased hearing

Pelvic pain

Phobia / Fear of things

Nasal congestion

Genital sores

Confusion

Nose bleeds

Decreased sex drive / libido

Hoarseness

Yes

No

Endocrinology

Yes

No

Musculoskeletal

Cold intolerance

Yes

No

Cardiovascular

Back pain

Heat intolerance

Chest pains

Joint pain

Constantly thirsty

Palpitations / Skipped beats

Joint swelling

Constantly hungry

Syncope / Fainting

Muscle cramps

Constantly need to urinate

Difficult breathing on exertion

Muscle weakness

Unusual weight change

Difficult breathing laying down

Stiffness

Shortness of Breath at night

Arthritis

Yes

No

Hemetology

Swelling in your legs or ankles

Sciatica / Pain down the legs

Unusual bruising

Restless legs

Unusual bleeding

Yes

No

Respiratory

Leg pain at night

Enlarged lymph nodes

Cough

Leg pain with exertion

Difficult breathing at rest

Yes

No

Allergy

Excessive sputum / phlegm

Hives

Coughing up blood

Allergic rash

Wheezing

Hayfever

Chest pain with deep breathing

Recurrent infections

Adult History Form - Female

Sexual Health is an important part of an individual’s overall physical and emotional well-being.

If I don’t ask about Sexual Health, patients will not always bring the issue up during the interview.

Therefore, I’ve begun asking all patients about their Sexual Health.

Female Sexual Health

Please answer the following questions as truthfully as possible.

1. In the past month, did you usually feel sexually aroused ("turned on") during sexual activity or intercourse?

___Yes ___ No

2. In the past month, have you been satisfied with the amount of vaginal lubrication (“wetness”) during sexual intercourse?

___Yes ___ No

3. In the past month, when you had sexual stimulation or intercourse, did you usually reach orgasm (climax)?

___Yes ___ No

4. In the past month, have you been satisfied with your sexual relationship with your partner?

___Yes ___ No

5. In the past month, did you experience discomfort or pain during vaginal penetration?

___Yes ___ No

6. Is your partner having sexual health issues that you would like to discuss?

___Yes ___ No

To the best of my knowledge, this is an accurate statement of my health:

Signature:____________________________________________ Date: _____-_____-_____