Fillable ADULT HEALTH QUESTIONNAIRE

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ADULT HEALTH QUESTIONNAIRE

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6028−13MR Rev. 01/30/18
ADULT HEALTH QUESTIONNAIRE
CURRENT MEDICATIONS (may bring own list to visit if you prefer)
ALLERGIES
PAST MEDICAL HISTORY (Check all that apply)
Page 1 of 3
Outside Note Other
Patient Name:
DOB: AGE:
Sex: ❏ M ❏ F
Patient Identification Area
Name of Medication
Strength of Medication
Dosing Instructions
* Note − this information may be taken directly from the pharmacy label on prescription products
❏ No Known Allergies ❏ Medication Allergies ❏ Environmental/Seasonal Allergies ❏ Latex Allergy
Who was your previous primary care provider?
What is your preferred Pharmacy?
Preferred language?
Written Spoken
Are you currently active in a religious community? ❏ Yes ❏ No
Religious Affiliation:
Education
: What is the highest level of education you have completed?:
❏ Grammar school
❏ High school or equivalent
❏ Some college
❏ Bachelor’s degree
❏ Masters degree ❏ Doctoral degree ❏ Other
Employment
: Are you currently employed? ❏ Yes ❏ No If yes; Employer:
Occupation:
History of hazardous work conditions (i.e. asbestos etc.) Type:
Example: Tylenol
Example: 500 mg Example: 1 pill three times a day
List Allergies
Reaction
❏ Acid Reflux/GERD
❏ ADHD
❏ Alcoholism
❏ Allergies
❏ Anemia
❏ Anxiety
❏ Arthritis
❏ Other (please list) −
❏ Asthma
❏ Bleeding Disorders
❏ Cancer
❏ Chronic Pain
❏ Depression
❏ Diabetes
❏ Emphysema/Bronchitis/COPD
❏ Epilepsy/Seizure Disorder
❏ Glaucoma/Cataracts
❏ Headaches
❏ Hearing Loss
❏ Heart Disease
❏ High Blood Pressure
❏ High Cholesterol
❏ Irritable Bowel
❏ Kidney Disease
❏ Liver Disease
❏ Osteoporosis
❏ Stroke
❏ Thyroid Disease
FAMILY HISTORY (Check all that apply)
SOCIAL HISTORY
Page 2 of 3
ADULT HEALTH QUESTIONNAIRE
Patient Identification Area
❏ Stroke
❏ Dementia/Alzheimer’s
❏ Asthma
❏ Cancer (please specify)
❏ Diabetes
❏ Depression
❏ Heart Disease
❏ High Blood Pressure ❏ High Cholesterol
❏ Thyroid Disease
❏ Other (please list) −
Personal Information
6028−12MR Rev. 01/30/18
PAST SURGICAL HISTORY
Date of Surgery (Operations) Type of Surgery (Operations)
GYN HISTORY
Number of Pregnancies:
Number of Living Children:
Marital Status
❏ Single ❏ Significant Other ❏ Married ❏ Divorced ❏ Widowed
Name of Significant Other/Spouse if applicable:
Children:
❏ Yes ❏ No Number of Sons Number of Daughters
Name and Ages of Children:
Living Situation: ❏ Live Alone ❏ With Significant Other/Spouse ❏ With Children/Family Members ❏ Other
Occupation:
Hobbies/Interests:
Tobacco
Have you ever smoked? ❏ Yes ❏ No If yes, what do you (did you) smoke?
Are you still smoking? ❏ Yes ❏ No
If no:
How many years ago did you quit?
For how many years did you smoke?
How many packs/day did you smoke?
If yes:
How many years have you smoked?
How many packs/day do you smoke?
Have you ever tried to quit?
Alcohol
Do you drink alcohol including beer, wine, or other alcohol? ❏ Yes ❏ No
If yes please specify frequency:
❏ Daily ❏ Almost Daily (4−6 times/week) ❏ 1−3 times per/week ❏ Less than one time/week
Do you drink caffeine? ❏ Yes ❏ No If yes, how many cups per day?
Illicit Drugs
Do you use any drugs or prescription medications not prescribed to you?
(including marijuana, cocaine, amphetamines, pain or anxiety medications, etc)
❏ Yes ❏ No
If yes, please specify type of drug and frequency of use −
Page 3 of 3
6028−12MR Rev. 01/30/18
HEALTH MAINTENANCE
Please provide the dates and results of the following immunizations, examinations, and tests to the best of your ability. If you
have not had one of these services, please indicate N/A (not applicable).
Diet/Activity
Are you on any special diet? ❏ Yes ❏ No
If yes, how would you describe your diet? (e.g. South Beach, Atkins, calorie intake, renal, diabetic, low sodium, low fat, etc.)
Do you currently participate in any regular activity to improve or maintain your physical fitness (either on your own or in a
formal class)? ❏ Yes ❏ No If yes, please describe:
ADULT HEALTH QUESTIONNAIRE
Patient Identification Area
Health Planning
Do you have Advanced Directives in place? ❏ Yes ❏ No
❏ Living Will ❏ Durable Power of Attorney ❏ Health Care Proxy ❏ Advanced Directives
All Patients:
Last Tetanus Booster
❏ Within past 10 years
❏ More than 10 years ago
❏ Unknown
Last Eye Examination
Last Hearing Exam
Date:
Date:
❏ Normal ❏ Abnormal
❏ Normal ❏ Abnormal
❏ Unknown
❏ Unknown
Last sigmoidoscopy / colonoscopy/
Date:
❏ Normal ❏ Abnormal ❏ Unknown
Or stool test
Last DEXA Bone Scan
Last Pneumonia Vaccine
Flu shot this season?
Date:
Date:
❏ Yes ❏ No
❏ Normal ❏ Abnormal
❏ Unknown
Women:
Last Pap Smear
Last Mammogram
Date:
Date:
❏ Normal ❏ Abnormal
❏ Normal ❏ Abnormal
❏ Unknown
❏ Unknown
Men:
Last Prostate Specific Antigen−PSA
Last Prostate Exam
Date:
Date:
❏ Normal ❏ Abnormal
❏ Normal ❏ Abnormal
❏ Unknown
❏ Unknown
CONCERNS
Please indicate any concerns regarding your health in the space provided.
Patient Name (printed):
Patient Signature:
Date:
We would like to personally thank you for taking the time to complete this form. Doing so provides us with the information
necessary to make the most out of each and every healthcare visit together.
Page 1 of 2
8402−03MR Rev. 10/07/19
AUTHORIZATION FOR RELEASE OF PROTECTED
OR PRIVILEGED HEALTH INFORMATION
Mail or Fax To:
Release of Information
121 Inner Belt Road, Room 240
Somerville, MA 02143−4453
Phone: 617−726−2361
Fax: 844−918-0781
Please print all information clearly in order to process your request in a timely manner.
A. PATIENT INFORMATION
PATIENT NAME:
PATIENT DATE OF BIRTH:
PATIENT MEDICAL RECORD #:
PATIENT ADDRESS: APT. #:
CITY:
STATE:
ZIP CODE:
TELEPHONE CONTACT #:
DAY: ( )
EVENING: ( )
STREET:
PERMISSION TO SHARE: I give my permission to share my protected health information. Enter where you would like
information sent from, and to whom you would like the information sent.
B.
FROM: (e.g. hospital, clinic, or provider name):
Name:
Address:
Telephone Number:
PURPOSE: (check the appropriate box):
❏ Medical Care
❏ Insurance*
❏ Legal Matter*
❏ Personal*
❏ School
❏ Other (please specify)*
* Copying fees may apply
TO: (e.g. to whom you would like the information sent):
❏
Check here if the records are to be mailed to the patient at the
above address (section A), otherwise complete the information
below to indicate where you would like the information sent:
Name:
Address:
Telephone Number:
SEND BY:
Partners Patient Gateway (if available)
Secure Email (provide email address below)
Patient Email Address:
Paper Copy via Mail
Fax (provide fax number):
❏
❏
❏
❏
INFORMATION TO BE RELEASED (Please check all that apply, and specify dates):
C.
Medical Record Abstract/dates:
(e.g. History & Physical, Operative Report, Consults, Test
Reports, Discharge Summary)
Clinic Visit Notes/dates:
Discharge Summary/dates:
Lab Reports/dates:
Operative Reports/dates:
Pathology Reports/dates:
❏
❏
❏
❏
❏
❏
Radiation Reports/dates:
Radiology Reports/dates:
Photographs/dates (costs may apply):
Billing Records/dates:
Other (please specify below and include dates):
❏
❏
❏
❏
❏
PRINT
SAVE AS
RESET
Page 2 of 2
8402−03MR Rev. 10/07/19
AUTHORIZATION FOR RELEASE OF PROTECTED
OR PRIVILEGED HEALTH INFORMATION
D.Please check YES to indicate if you give permission to release the following information if present in your record:
HIV test results (PATIENT AUTHORIZATION REQUIRED FOR EACH RELEASE REQUEST.)
SPECIFY DATES:
Genetic Screening test results (SPECIFY TYPE OF TEST):
Alcohol and Drug Abuse Records Protected by Federal Confidentiality Rules 42 CFR Part 2 (FEDERAL RULES
PROHIBIT ANY FURTHER DISCLOSURE OF THIS INFORMATION UNLESS FURTHER DISCLOSURE IS
EXPRESSLY PERMITTED BY WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS OR AS
OTHERWISE PERMITTED BY 42 CFR PART 2.) This consent may be revoked upon oral or written request.
Other(s): Please List:
Details of Mental Health Diagnosis and/or Treatment provided by a Psychiatrist, Psychologist, Mental Health
Clinical Nurse Specialist, or Licensed Mental Health Clinician (LMHC) (I understand that my permission may not
be required to release my mental health records for payment purposes)
Confidential Communications with a Licensed Social Worker
Details of Domestic Violence Victims’ Counseling
Details of Sexual Assault Counseling
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
E. I understand and agree that:
Partners HealthCare System (PHS) cannot control how the recipient uses or shares the information, and that
laws protecting its confidentiality at PHS may or may not protect this information once it has been released to
the recipient
This authorization is voluntary
My treatment, payment, health plan enrollment, or eligibility for benefits will not be affected if I do not sign this form
I may cancel this authorization at any time by submitting a written request to the Department or Office where I originally
submitted it, except:
if PHS has already relied upon it (for example, once information is released, it will not be retrieved)
if I signed this authorization as a condition of obtaining insurance, other laws may provide the insurer with a right to
contest a claim under the policy or the policy itself
This authorization will automatically expire 6 months from the date signed unless otherwise specified:
I understand that if Partners maintains any of my records from outside providers, these will not be released unless I
specifically ask for them under "Other" in section C. Please include entity name, provider, and specific dates if known.
My questions about this authorization form have been answered
●
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❍
❍
➢ Patient’s Signature:
➢ Date:
➢ Print Name:
When patient is a minor, or is not competent to give consent, the signature of a parent, guardian, or other legal representative
is required.
➢ Signature of Legal Representative:
Date:
Print Name:
Relationship of representative to patient:
For Internal Use Only
Information Released/Reviewed By:
Date:
Clinic/Office:
Pick−up Identification:
❏ License ❏ State ID ❏ Passport ❏ Other Photo ID
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ADULT HEALTH QUESTIONNAIRE

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Completed 11 February 2021

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