Microsoft word - health history rev 05012013.docx
Patient Name______________________________________________ Today’s Date____________________ Age:________________
Mail Order Pharmacy Name/Address:
__________________________________________________________
Phone:____________________________________
Local Pharmacy Name/Address:
______________________________________________________________
Phone: ___________________________________
Allergies? (Circle)
Yes (if yes, please list below) or
No ______________________________________________________________________________________
______________________________________________________________________________________
Medication List
Please list all medications: Prescription/over the counter/vitamins/supplements
List dosage and how often you take
Example: Flomax 0.4 mg 1 tablet a day Name
1.________________________________ __________ ________________________________
2.________________________________ __________ ________________________________
3.________________________________ __________ ________________________________
4.________________________________ __________ ________________________________
5.________________________________ __________ ________________________________
6.________________________________ __________ ________________________________
7.________________________________ __________ ________________________________
8.________________________________ __________ ________________________________
9.________________________________ __________ ________________________________
10.________________________________ __________ ________________________________
Surgical History
List all Surgery from childhood to present including year of surgery. Example: Tonsils removed 1989
1.______________________________________________________________________________________
2.______________________________________________________________________________________
3.______________________________________________________________________________________
4.______________________________________________________________________________________
5.______________________________________________________________________________________
6.______________________________________________________________________________________
7.______________________________________________________________________________________
Patient Name______________________________________________ Today’s Date____________________
SYMPTOMS: Check (√) symptoms you currently have or have had in the past year.
CONSTITUTIONAL
EARS, NOSE, MOUTH,
CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
INTEGUMENTARY/
NEUROLOGICAL
HEMATOLOGIC/
LYMPHATIC
□ Persistent Itching
CONDITIONS: Check (√) conditions you have or have had in the past. □ AIDS
□ Constipation
Source: http://www.southwesturology.com/patientforms/healthhistory_2014.pdf
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Disease Management ABOUT OUR FORMULARY FORMULARIES What is a formulary? “Open” Formulary A formulary is a listing of prescription medications that are preferred for use A plan that has adopted an “Open” formulary allows coverage for both by a plan and are dispensed through participating pharmacies to covered formulary and non-formulary drugs. Drug coverage is not d