Complete Medical History
- What medical problems have you been told you have?
- Have you ever been told you have diabetes or high blood pressure?
Past Surgical History
- Have you ever had any surgeries?
- Do you still have your gallbladder?
Family history
- Do you know of any medical problems in your family?
Psych history
Have you ever been diagnosed with a mental health disorder or received mental health treatment or counseling? Are you currently taking any psychiatric medications? (see mental health screening below)
Social history
Living Situation: a. Where do you currently live? (e.g., own home, rent, assisted living) b. Who lives with you at home, if anyone? c. How would you describe your living conditions (e.g., safe, clean, accessible)? Employment and Education: a. What is your current occupation, and how long have you been employed in this role? b. Are you a student, and if so, where do you attend school? c. Have you experienced any work-related stress or difficulties? d. What is your highest level of education? Financial Status: a. Do you have a stable source of income? b. Are you facing any financial difficulties, debt, or unemployment? c. Do you have health insurance coverage? Support System: a. Who are your primary sources of support, both within and outside of your family? b. Are there any significant relationships that affect your health or well-being (e.g., spouse, partner, close friends)? Cultural and Religious Background: a. What is your cultural or ethnic background? b. Are there any specific cultural or religious practices that are important to you? c. Do your cultural or religious beliefs impact your healthcare decisions? Legal Issues: a. Are you currently facing any legal problems, such as court cases, probation, or legal restrictions? b. Have you ever been involved in legal issues that could impact your health? Hobbies and Interests: a. What are your hobbies, interests, or activities you enjoy outside of work or daily responsibilities? b. How do you usually spend your leisure time? Substance Use: a. Do you use alcohol, tobacco, or recreational drugs? If yes, how often and in what quantities? b. Have you ever had a history of substance abuse or addiction treatment? Transportation: a. How do you usually get around (e.g., personal vehicle, public transportation)? b. Do you have reliable transportation for medical appointments? Social and Environmental Stressors: a. Are there any significant stressors in your life, such as family conflicts, housing instability, or exposure to violence or abuse? b. Do you have concerns about environmental factors that could affect your health (e.g., pollution, safety)? Health Literacy: a. How comfortable are you with understanding and managing your own health, including medications and medical information?
Medications
- Have you ever taken any medications regularly?
- Do you take any medications currently?
Allergies
- Do you have any allergies to food or medications? What happens if you eat the food or take the medication (i.e. anaphylaxis vs rash)?
Immunization history
Childhood vaccinations (MMR, etc) Hep B TDaP Shingrix HPV Flu COVID
Mental health screening
General Well-being: How have you been feeling overall in recent weeks? Have you noticed any significant changes in your mood or behavior? Depression: Have you experienced persistent sadness, hopelessness, or low energy? Do you have trouble sleeping or sleeping too much? Have you lost interest in activities you once enjoyed? Anxiety: Do you often feel worried, anxious, or have a sense of impending doom? Have you experienced panic attacks or physical symptoms like rapid heartbeat or sweating in response to anxiety? Suicidal Thoughts: Have you had thoughts of self-harm or suicide? Do you have a plan for harming yourself, and do you feel you can control these thoughts? Self-Harm and Risky Behaviors: Have you engaged in self-harming behaviors (e.g., cutting, burning) or risky behaviors (e.g., substance abuse, unsafe sex)? How do you cope with stress and emotional pain? Substance Use: Do you use alcohol, tobacco, or recreational drugs, and if so, how often and in what quantities? Have you experienced difficulties related to substance abuse or addiction? Trauma and PTSD: Have you experienced a traumatic event, and do you have symptoms like flashbacks, nightmares, or avoidance related to that event? Sleep Disturbances: Do you have trouble sleeping or staying asleep, and do you feel fatigued during the day? Eating Habits and Body Image: Do you have concerns about your eating habits, body image, or have you experienced changes in weight? Have you ever been diagnosed with an eating disorder? Social Support and Stressors: Do you have a strong support system in your life, or do you feel socially isolated? Are there major sources of stress in your life, such as relationship issues, work-related stress, or financial problems? Psychotic Symptoms: Have you experienced hallucinations or delusions (hearing voices, believing in things that others do not)?
Baseline Labs:
[ ] A1c (if risk factors) [ ] Lipid panel [ ] CBC [ ] CMP [ ] STI screening: RPR, HIV, urine G/Ch [ ] Hep B titers [ ] HCV Ab [ ] Assess risk factors for colon cancer (ie. family history) to determine when to start screening colonoscopy (if <45yo)
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