RFCC Clinical Intake Form (Provider RFCCs)

RURAL/FRONTIER WOMEN’S HEALTH COORDINATING CENTERS

Women’s Wellness and Maternity Center

Extensive Health History Form

Extensive Health History								Health Provider Notes
								Please Do Not Write In This Area
Last Name: First: Age: Sex:
Current Problem:
Have you or any blood relative had:
			Yes	No	Who		Year
Allergies, asthma, hay fever
Anemia
Alcoholism
Arthritis
Bleeding problems
Birth defects
Cancer
Diabetes
Emphysema
Epilesy or seizures
Heart trouble
Mental illness (depression,
anxiety, panic attacks)
Migraine headaches
Rheumatic fever
Stroke
Suicide
Thyroid disease/goiter
Tuberculosis
Ulcers
Sexually transmitted infection
Chlamydia
Gonorrhea
Herpes
HPV/warts
Syphilis
Osteoporosis
Glaucoma
Gallstones
Rubella / Berman Measles
Toxoplasmosis
Cytomeglovirus
Hepatitis A
Hepatitis B
Hepatitis C
Names of other Present MDs					Childhood
What did you see them for:				Year	Immunizations		Year
					Tetanus
					Diphtheria
					Polio
					Pneumovax
					Flu shot
					Last TB Test
					Positive Negative
Allergies: Please list type and reaction None
Name of Drug/Item			Reaction

Patient Name:
Medications							Health Provider Notes
Have you EVER		Yes	No	How long(years)		Brand/Descr/Dose	Please Don't
TAKEN:							Write In This
Blood pressure pills							Area
Cortisone/steroid
Diet pills
Diabetes pills
Thyroid pills
Tranquilizers
Water pills
Are you NOW taking:
Antacids
Asprin or Antibiotics
Blood thinner pills
Laxatives
Pain pills
Sleeping pills
Vitamins
Herbal Supplement
OTHER Please list
OB/GYN HISTORY
		Yes	No	Answer
Date of last menstrual period
Are your periods regular?
No. of days between periods
No. of days periods last
Spotting betweeen periods
Do you do self breast exams monthly?
Are you pregnant?
No. of pregnacies
Date of last pregnancy
No. of live births
Complication with pregnancy?
Complication with delivery?
Hours in labor
Pain Medication
On due date were you early or late?
No. of abortions or miscarrages
Date of last pap smear
Was It normal?
Any other abnormal Pap?
Treatment for abnormal Pap
Are you using anything to avoid pregnancy?
Type of contraception
Type of contraceptives used in past
Did your mother take DES during her pregnancy?
Last mammogram
Surgical History: Name of Operation		Date		Complications
		Yes	No	Date
Have you ever had any bleeding problems?
Have you ever had a blood transfusion?
MAJOR ILLNESS OR INJURY:list any illness or
injury requiring hospitalization, prolonged care, or
use of medication. Include approximate date.

Patient Name:
PERSONAL HABITS/RISK FACTORS					Health Provider Notes
	Yes	No	Answers		Please Don't Write In This Area
Do you smoke or chew tobacco?			pack/	day:
Have you ever smoked in the past?			Date started:
			Date stopped:
Do you often eat 3 meals/day?
Do you snack regularly?
Do you diet regularly?
Do you have an eating problem?
Any diet preferences/restrictions?
Type
Dietary habits			Frequency or No.:
Low Fat
No. serving/day vegetables/fruits
No. servings/day grains
No. times/week you eat red meat
No. servings/day dairy
No. caffeine drinks/day
Ave. alcoholic drinks/day
No.of times "drunk"/year
Ever had a drinking problem?
Ever had a drug problem?
Ever used street drugs?			Date last used:
Do you ever not use seat beat?
No. hours sleep/day
Highest grade level achieved
Do you know how to swim?
Do you exercise regularly?
What exercise do you do?
How often/week?			Duration:
What do you to relive stress?
Any pets?
Any hobbies?
Occupation:
Do you like your job?
Is your job a risk to your health?
If yes (in any way), please explain:
Do you have cats?
Do you change the liter box?
Do you handle raw meat?
Do you work with children?
SOCIAL HISTORY	Do you have children?
Are you: Married	(step-children, foster children, ect.)
Separated Single	Yes, please list names & yearborn
Divorced Widowed
Living with "signif. other"
SEXUAL HISTORY	Yes	No	Lifetime
Are you sexually active?			Sexual Partners
Any problems with sex drive?			No. men
Does sex hurt?			No. women
Do you bleed after sex?			No. unprotected
History of Chlamydia?
Gonorrhea?			How old were you when
Venereal warts/HPV?			started having sex?
Herpes?
Syphilis?
Are you concerned about AIDS?
Would you like to have a test?

Navigant Consulting Inc. Appendix F-2

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