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Charles G Huntington (DOB 111149)

By Cathy West,2014-05-06 08:37
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Charles G Huntington (DOB 111149)

Questions you were

    never asked…

but should have been

    _________

    Handout

    Charles G. Huntington, PA, MPH

    860-679-7968

    huntington@adp.uchc.edu

    Medical History Information Collection Template

    Past medical history

    Current illnesses

     First current illness:

     Date started: Treating physician:

     How treated:

     Second current illness

     Date started: Treating physician:

     How treated:

     Third current illness

     Date started: Treating physician:

     How treated:

     Fourth current illness

     Date started: Treating physician:

     How treated:

    Significant past illnesses

     First past illness:

     Dates: Treating physician:

     How treated:

     Second past illness:

     Dates: Treating physician:

     How treated:

     Third past illness

     Dates: Treating physician:

     How treated

     Fourth past illness

     Dates: Treating physician:

     How treated:

    Past operations (surgical procedure)

     First past operation:

     Date: Hospital:

     Second past operation:

     Date: Hospital:

     Third past operation:

     Date: Hospital:

     Fourth past operation:

     Date: Hospital: Significant injuries

    Page 1

     First significant injury:

     Date: Treating physician:

     How treated:

     Second significant injury:

     Date: Treating physician:

     How treated:

     Third significant injury:

     Date: Treating physician:

     How treated:

    Other hospitalizations

     Reason for first hospitalization:

     Dates: Hospital:

     Reason for second hospitalization:

     Dates: Hospital:

     Reason for third hospitalization:

     Dates: Hospital:

    Do you have any history of:

     Heart disease ? Yes

    ? No Date started: How treated:

     Diabetes ? Yes ? No Date started: How treated:

     Cancer ? Yes ? No Date stared: How treated:

    Do you have any allergies? ? Yes ? No If yes, please list them below.

     Cause: Type of reaction:

     Cause: Type of reaction:

     Cause: Type of reaction:

    Are there any medications you cannot take? ? Yes ? No If yes, please list them below.

     Medication: Type of reaction:

     Medication: Type of reaction:

     Medication: Type of reaction:

    Current prescription medications

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

    Page 2

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day: Current over-the-counter medications

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day: Current vitamins, supplements, or herbal products

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day:

     Name: Dosage (mg): Times per day: Immunizations

     Date of last Tetanus/ Diphtheria vaccination:

     Date of last Pneumonia vaccination:

     Date of last flu shot:

    Family Medical History

    Current age: Mother

     Significant illnesses:

     If deceased age at death: Cause of death:

    Current Age: Father

     Significant illnesses:

     If deceased age at death: Cause of death:

     Sibling 1: ? brother ?

    sister Current Age:

     Significant illnesses:

     If deceased, age at death: Cause of death:

    Page 3

    ? brother ? Sibling 2:

    sister Current Age:

     Significant illnesses:

     If deceased, age at death: Cause of death:

     Sibling 3: ? brother ?

    sister Current Age:

     Significant illnesses:

     If deceased, age at death: Cause of death:

     Sibling 4: ? brother ?

    sister Current Age:

     Significant illnesses:

     If deceased, age at death: Cause of death:

     Sibling 5: ? brother ?

    sister Current Age:

     Significant illnesses:

     If deceased, age at death: Cause of death:

     Sibling 6: ? brother ?

    sister Current Age:

     Significant illnesses:

     If deceased, age at death: Cause of death:

    Ages of children: Number of children:

     Significant illnesses:

     If deceased, age(s) at death: Cause(s) of death: Any family history of: ? Heart disease ? Diabetes ? Cancer ? Alcohol or substance abuse

    Social history

     Marital status: ? Single ? Married ? Divorced ? Widowed

     With whom do you live?

     Current occupation:

     Previous occupations:

     Exposures to chemicals or other hazardous agents: ? Yes ? No

     If yes, please describe:

     Regular exercise: ? Yes ?

    No Type of exercise:

     Typical duration (mins.): How many days per week: Smoking or other tobacco use: ? Yes ? No

    How many packs per day: For how many years: If you quit, how long ago:

    Alcohol use: ? Yes ? No

    How many beers, glasses of wine, or cocktails on average day that any alcohol consumed:

    On how many days per week or month: ? per week ? per month

    Page 4

    ? Yes ? No Do you use any recreational drugs:

    If yes, which drugs?

    How much in typical day:

    On how many days per week or month: ? per week ? per month

    New Problem Visit with Your Current Physician ? Tell the story of this new problem from the beginning up until the present time ? Describe each symptom in the order that they developed according to the following

    characteristics:

    Quality

    Describe the symptom in your own words (e.g., is the pain is sharp or dull):

Severity

    Rate the severity of the symptom on scale of 1 to 10, with 1 being hardly noticeable and ten

    being the worst you can imagine.

Location

    Where is the symptom? If pain, point to where the pain seems to be centered.

Where did the pain or symptom start?

Did the symptom spread or radiate to another location?

Time course

    When did you first notice the symptom?

    How has it changed since it started and up until the current time?

Is the symptom constant or does it come and go?

If it comes and goes, how long does it last when present, and how often does it occur (how many

    times per day or per hour)?

Does it tend to occur at any particular time of day?

    Page 5

Page 6

Setting

    In what setting does it occur? (e.g., at night, at work but not at home)

What makes it worse or better

    What makes the symptom worse? (e.g., position, walking, movement, eating a particular food)

What makes the symptom better? (e.g., lying down, taking Tylenol)

    What have you tried to make it better and what kind of response did you get?

Impact

    How has the current illness affected your life? What could you do before that you cannot do

    now (e.g., unable to work, unable to walk as far, loss of appetite)

Associated symptoms

    Any other symptoms occurring since the current illness started?

Preceding events

    Any changes in your life before problem started? (e.g., new medication, new exercise program)

Your opinion

    What do you think the problem is?

    Page 7

    Routine follow-up Visit Template Are you having any symptoms that suggest that your problem is getting worse?

    List all of your current medicines (name, dosage, and number of times taken per day).

    Describe any problems you have had in taking your medicines as prescribed.

Are you having any undesirable side effects from your medicines?

    Record any relevant measurements such as blood sugar of blood pressure readings. A spreadsheet or table showing the trends in these measurements over time can be very helpful to

    your physician (See the sample spreadsheet on last page of this handout).

What questions do you have?

    Page 8

    Sample Past Medical History

Robert Smith (DOB: 10/11/39)

Date: March 1, 2008

    Past medical history -

Illnesses: Normal childhood diseases without sequelae

     Rheumatoid arthritis, diagnosed 1997; Dr. George Strait

Surgery: Tonsils and adenoids removed, 1947 (general); Greenwich Hospital

     Appendectomy, 1951 (general); Greenwich Hospital

     Arthroscopic surgery left rotator cuff surgery, 1987; UConn Health Center

Injuries: Dislocated left elbow, 1968

Allergies: None

    Medication Intolerances: Sulfa (causes fever)

     Ibuprofen (causes migraine headache)

    Immunizations: DT, 12/11/2002; Hepatitis A, 12/11/2002, 06/09/2003

Present medications: Mobic 7.5 once a day, Arava 20mg once a day, Enbrel 25mg twice a week,

    Prednisone 10mg once a day when necessary

Family history -

Mother: deceased age 75 years; emphysema, cancer of mouth x 2

    Father: deceased age 87 y.o.; Alzheimer’s

    Sister: deceased age 22 years; leukemia

    Brother: 63 y.o.; alive and well; History of asthma

    Sister: 58 y.o.; alive and well; History of alcoholism

    Brother: 55 y.o.; alive and well; History of rheumatic heart disease, possible FAS

    PGM: deceased age 72 years; heart disease

    PGF: deceased age 97 years; asthma

    MGM: deceased mid to late 60s; died in sleep, probable stroke or MI

    MGF: deceased mid to late 60s; cause?

    Paternal aunt: deceased age 95 y.o.; colon cancer; History of breast cancer and thyroid disease

    Son: 26 y.o.; alive and well; History of asthma

Social history -

    Marital status: Married; live with wife (attorney) and 11 y.o. daughter (adopted) in West Hartford; four

    other children (3 adopted) are out of the house and on their own. Occupation: Account with firm in Hartford; No know occupational exposures

    Habits: Never smoked; 1-2 drinks per week; regular exercise 45-minutes, 5-6 times per week; No

    recreational drugs.

    Page 9

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