Do you have any of the following? Please check all that apply. Skin/Breast Constitutional symptoms Neurological Hematologic/Lymphatic Gastrointestinal Breast lump Anemia (low blood count) Hepatitis (type_____) Unusual mole Bleeding tendency Liver disease Skin rash Blood clots Jaundice (yellow skin) Blood disease Blood in stool Swelling of glands Abdominal pain Seattle Premier Health Patient Registration Please complete this form and return it to Seattle Premier Health at 1600 E Jefferson St, Suite 115, Seattle, WA 98122. If you prefer, you may fax it to our office at 206-215-4315. Please call 206-215-4300 with any questions. Loss of appetite Seizures Fatigue Multiple sclerosis Weight loss Migraine headaches Latex sensitivity Recent vomiting Weight gain Fainting spells HIV/AIDS Recent diarrhea General Information Personal Medical History Obesity Stroke/TIA Chicken pox Heartburn Name (Last) Seasonal allergies Feeling full early Please list any medical problems (past or present) and the date(s) they occurred. Anorexia/bulimia Genitourinary Kidney disease Eyes Allergic/Immunologic Cardiovascular Abdominal bloating (First) _______________________________________ (MI) _________ Peptic ulcer disease Age________ Date of birth_____/_____/_____ Glaucoma Kidney stones Congenital heart disease Difficulty with vision Herpes Circulatory problems ___________________________ Other (please describe) Trouble urinating Pacemaker ___________________________ Sexual concerns Heart murmur Oncology ___________________________ ___________________________ ___________________________ Ears, Nose, Mouth and Throat Sinusitis Hearing loss Dizziness Yeast infections or bladder infections Psychiatric Chemical dependency Anxiety Depression Sleep disorder Endocrine Heart problems High blood pressure Elevated cholesterol Chest pain/pressure Respiratory Asthma Other (please describe) Place of birth _______________________________________________ Height __________________ Usual weight _______________________ Current weight ______ How long at current weight ______________ Cancer If yes, are you receiving chemotherapy? Yes _______________________________________________ No Are you now or could you be pregnant? Yes No Have you traveled outside the United States in the past five years? Yes No _____________________________________________ ___________ _____________________________________________ ___________ _____________________________________________ ___________ _____________________________________________ ___________ _____________________________________________ ___________ _____________________________________________ ___________ _____________________________________________ ___________ Date of last physical exam ____________________________________ If yes, where? _______________________________________________ Pneumonia Are you currently under medical treatment? Yes No Emphysema Allergies If yes, for __________________________________________________ Cough List allergies to foods, medicines and medical products, such as tape or latex. ___________________________________________________________ Tuberculosis Allergy Reaction Medications Other (please describe) ______________________________ __________________________ ______________________________ __________________________ ______________________________ __________________________ Back problems ______________________________ __________________________ ___________________ ______ ___________________ _________ Fracture/broken bones ______________________________ __________________________ ___________________ ______ ___________________ _________ Sore throat Sleepy during the day Loud snoring at night Sleep apnea Musculoskeletal Diabetes Hot or cold all the time Thyroid disease Shortness of breath Arthritis ___________________________ Rheumatic fever ___________________________ Joint pain Other (please describe) List all prescription medications, over-the-counter drugs, supplements, herbs and vitamins you are currently taking, or have taken in the last month. Medicati on Name Dose Frequency (in mgs) (times per day) Last Dose ___________________________ Questions/Health Concerns ___________________ ______ ___________________ _________ ___________________________ Do you have any questions or health concerns we should know about, or conditions you would like evaluated? ___________________ ______ ___________________ _________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Seattle Premier Health ___________________________________________________________ ___________________ ______ ___________________ _________ ___________________ ______ ___________________ _________ ___________________ ______ ___________________ _________ ___________________ ______ ___________________ _________ 1600 E Jefferson St Suite 115 Seattle, WA 98122 ©20 S,(;;3, HEALTH SERVICES Do you take any of the following? Daily aspirin ___________ mg Antioxidants Sleeping medications, tranquilizers Recent Tests and Screening Exams Alcohol and Drug Use Date of most recent: Tobacco use: Colonoscopy________________________________________________ If ever, how much each day?___________________________________ Any family history of the following? For how many years?___________ When did you quit?___________ Alzheimer’s disease Anxiety/depression Bleeding disorders Cancer: Breast Colon Melanoma Ovarian Prostate Other Diabetes Heart attack Heart bypass surgery Angioplasty (stent) High blood pressure Kidney disease Kidney stones Osteoporosis Stroke Other _______________________________ Acetaminophen, ibuprofen Mammogram________________________________________________ Anticoagulants Pap smear___________________________________________________ Daily calcium supplement ___________ mg Daily vitamin D supplement or multivitamin EKG Oral contraception/estrogen replacement Please list all previous surgeries and procedures. Year Surgeon ________________________ _______ _ _______________________ ________________________ _______ _ _______________________ ________________________ _______ _ _______________________ ________________________ _______ _ _______________________ ________________________ _______ _ _______________________ Yes No Yes No Cardiac stress test Date of most recent test for: Cholesterol and blood sugar levels Total cholesterol_____________________________________________ LDL cholesterol______________________________________________ Tetanus ____________________ Tetanus/pertussis ____________________ Pneumovax ____________________ Flu ____________________ Past Now Past For how many years?___________ When did you quit?___________ Never Now Past If ever, how much each day?___________________________________ Exercise and Diet Number of times per week you exercise: 0 1 2 3 4 5 6 45 60 90 7 Minutes duration for each session: 10 15 HDL cholesterol_____________________________________________ If yes, please list______________________________________________ If yes, when?_ _______________________________________________ Never Stress level: Immunizations/Date of Last Booster Now For how many years?___________ When did you quit?___________ Type of activities Have you had serious injuries or broken bones in the past? Though some questions may seem repetitive, your answers will help our physicians best understand your family medical history. Past If ever, how much each day?___________________________________ Triglycerides_________________________________________________ Blood sugar_________________________________________________ Now Never Caffeine use: Date_ ___________________ Normal: ________________________ _______ _ _______________________ Have you had blood products transfused at any time?_ ____________ Alcohol use: Drug use: Date_ ___________________ _Normal: Surgeries and Procedures Surgery Bone density_________________________________________________ Never Family Medical History Low 20 Average 30 Race or nationality of parents__________________________________ Living Present Age or Age at Death Above average High Very high How would you describe your diet? Please check all that apply. Maternal Paternal Significant Health Problems or Cause of Death Father: Yes No ____________ _____________________ Mother: Yes No ____________ _____________________ Vegetarian Low-fat diabetic Spouse/domestic partner: Red meat (primarily) Low-salt Mediterranean Poultry/fish (primarily) Check if you eat dairy products Yes No ____________ _____________________ Maternal grandmother: Fish only Check if you are lactose-intolerant Personal Safety Do you: Yes No ____________ _____________________ Maternal grandfather: Always _Sometimes _Never Yes No ____________ _____________________ Paternal grandmother: For Women Hepatitis A ____________________ Start date of last menstrual period ______________________________ Hepatitis B ____________________ Have smoke detectors in your home? Yes No ____________ _____________________ Paternal grandfather: Periods are: German measles (rubella) ____________________ Have a carbon monoxide detector? Measles ____________________ Wear your seatbelt when riding in a car? Brothers: Number living________ Number dead_________ Talk on your cell phone while driving? Significant health problems____________________________________ Polio ____________________ Have guns in your home? Varicella ____________________ If yes, are they locked? Zostavax (shingles) ____________________ Human papillomavirus (HPV) ____________________ Have an advanced directive? ____________________ If yes, date last updated? Regular Irregular Number of pregnancies_ ______________________________________ Number of miscarriages_______________________________________ History of abnormal Pap smear? Yes No Have you experienced early menopause or amenorrhea? Yes No Other immunizations Post-menopausal (menopause at age__________) Take estrogen: Never Currently Past Wear a helmet when riding a bike? No ______________ _______________________ __________________________________________________________________ ___________________ Cause(s) of death_____________________________________________ ___________________________________________________________ Have a living will? If yes, date last updated? Yes ___________________ Sisters: Number living________ Number dead_________ Significant health problems________________________________________ ___________________ __________________________________________________________________ Cause(s) of death_____________________________________________ ___________________________________________________________ Children: Number living________ Number dead_________ Significant health problems________________________________________ __________________________________________________________________ Cause(s) of death__________________________________________________ __________________________________________________________________ ©20 S,(;;3, HEALTH SERVICES