USF Physicians Group
University of South Florida, Morsani College of Medicine Department of Family Medicine

Welcome to the USF Department of Family Medicine Health Clinic. If you are a new patient or have not seen us for 2 years, please complete the following 6 page health history prior to your appointment. Feel free to ask for assistance from the staff or your provider if you are unsure how to answer a question.
Name:	Date:  	

What name would you like to be called?  	

Pharmacy Name:	Phone Number:  	

Date of birth:	/	/   _
M	D	Y
Home phone:	Work phone:  	

Email:	Cellular phone:  	

Preferred Method of Contact:  	

In case of emergency, contact:  	

Phone:	Relationship:  	

Please state reason for today’s visit:  	

Birthplace:  	

Is Tampa area your primary home?   	

Education: c middle school  c high school  c college degree	c post college degree

Occupation:  	

Are you a caregiver for a family member?  c Yes c No

If yes, briefly describe your role  	

Married? c Yes c No  How many years?	Occupation (spouse/partner):  	

Who lives with you in your home? (Spouse, partner, children, in-laws, boyfriend, girlfriend, pets (dogs, cats, other animals)  	 

Do you have a “living will” or other advanced directive Yes or No If yes, where is it filed?  	 
If no, would you like information today? cYes c No  if yes, date given:	nurses initials  	

Allergies to Medications
Medication	Reaction	

		

Current Medications  (please  include  over  the  counter  medications  and  food supplements)
Drug Name	Dose	How Often?	Drug Name	Dose	How Often?	

						

						

Your Health History (Check if you have had any of the   following)

	

	

	

	

Abnormal Heart Rhythm Allergies/Seasonal/ Environmental

Anemia Anxiety/Stress Asthma Arthritis
Atrial Fibrillation Back Pain
Colitis or Crohn's Disease Cancer (Any type) Chronic Bronchitis

Chronic Pain

	

	

	

	

Chronic Kidney Disease Depression
Diabetes Diverticulitis Emphysema/COPD Gall Bladder Disease Gout
Headaches/Migraines Heart Attack Heartburn (GERD)

Heart Failure

	

	

	

	

Heart Murmur Hepatitis
High Blood Pressure High Cholesterol HIV/AIDS
IBS
Kidney Failure Kidney Stones Mental Illness Obesity

Osteoporosis Peripheral Vascular Disease

	

	

	

Seizures/Epilepsy

Sleep Apnea Stomach Ulcers Stroke
Thyroid Disease Urinary Tract Infection

Please list any hospitalizations and surgeries with approximate dates:

Have you had blood transfusions:  c	Yes or c	No How many hours a night do you sleep?  			 
Any trouble falling asleep? c Yes c No Any trouble staying asleep? c Yes c No
Have you been told you snore loudly? c Yes c No If so, do you fall asleep easily during the day?   	

In the past 7 days, how many times have you used an over-the-counter or prescription sleep aid?  	

Preventive Health History
Check if you have had any of the following and provide date (month and year and/or results)

	

	

	

Colonoscopy Cardiac Stress Test Mammogram
Bone Density Pelvic and Pap
Cholesterol Screening

Date	Results

	

	

Vaccines Tetanus (Td or Tdap) Pneumonia
Zostavax (Shingles) Hepatitis B Influenza (flu)

Date

Prostate Antigen Test (PSA)

Have you traveled or are you planning a visit outside of the United States? c Yes c No If yes, list locations and dates:  	
Is medical information presented to you in an easy to understand manner?
c Never c Occasionally c Sometimes c Always

How often are medical forms difficult to understand and fill out? c Never c Occasionally c Sometimes
c Always

How often do you have problems learning about your medical condition because of difficulty understanding written information? c Never c Occasionally c Sometimes c  Always

What are your hobbies?  	

How would you rate your diet?  c Excellent c Good c Fair c Poor

Do you have any food allergies or intolerance? c Yes c No
Specify:  	

Do you follow a special diet or nutrition plan? c Yes c No
Specify: 	

Tobacco use:  Smoking history:  c Never smoked	c Started (age)  	

c Stopped (age)  	

How many packs per day do you now smoke now  	

in the past  	

Do you dip or chew tobacco? c Yes c No

Do you drink alcoholic beverages? c Yes c No
If yes, please estimate how much you drink:   	

Glasses/cans per day/week/month (circle one)

Have you ever had a drinking problem? c Yes c No	When was your last drink?  	

How many cups of coffee, tea, or other caffeine products (like Coke) do you drink daily?  	

Do you use, or have you used marijuana, cocaine, IV drugs, or other street drugs? c Yes c No Do you consider yourself the appropriate weight? c Yes c No

If No, what do you think an appropriate weight would be for you?   	

Describe your regular physical activity or exercise program:
Type: 				  Frequency:	days per week	Duration:	minutes
Intensity:  c Low c Moderate c High

Do you see a dentist? cYes c No  Last visit date:   	

Do you see an eye doctor? c Yes c No  Last visit date:  	

How often do you wear seat belts?   c Always	c Occasionally  c Never

Were you adopted? c Yes  c No	if no, complete the following table:
Family History
Maternal	Paternal
Mother	Father	Grandparents Grandparents	Brother	Brother	Sister	Sister

								

								

								

								

Breast Cancer Colon Cancer Diabetes Heart Attack
High Blood Pressure High Cholesterol Lung Cancer Prostate Cancer Skin Cancers
Stroke
Other (Please Specify):

If your mother, father, brothers or sisters are deceased, please list their age at the time of death and the cause:

How do you rate your overall health: c Excellent c Good c Fair c Poor Please check any of the following that apply to you:
YES  NO
 	History of STI’s (sexually transmitted infections):

(HPV, genital warts, chlamydia, herpes, gonorrhea, syphilis, other	_)
 	  	_Have you ever been tested for HIV disease?
If Yes, what year?  	   If No, would you like to be tested? c Yes c No

Are you sexually active? c Yes c No	Age of first sexual encounter (intercourse)  	  If yes: Are your sexual partners c Male c Female c Both

YES  NO
 	Do you feel safe in your current relationship?

 	Do you feel afraid of a partner/spouse?

 	Have you ever, or are you currently suffering abuse (slapping, hitting, choking, yelling, threatened) in your relationship?   If Yes:   	

 	Are your friends and family aware of any problems/abuse in your relationship?

 	Do you have an emergency escape plan and somewhere safe to go?

Over the past 2 weeks, how often have you been bothered by any of the following problems: Little interest or pleasure in doing things
c Not at all  c Several days  c More than half the days c Nearly everyday

Feeling down, depressed or hopeless
c Not at all  c Several days  c More than half the days  c Nearly everyday

Systems Review
Please check any of the following  that you have experienced or are a concern to you

Constitutional
Weight Gain/Loss	o
Fatigue	o
Fever or Sweats	o
Headache	o
Eyes
Glasses/Contacts	o
Cataracts	o
Double Vision	o
Glaucoma	o

Respiratory
Cough	o
Coughing Blood	o
Wheezing	o
Shortness of Breath	o
Gastrointestinal
Heartburn	o
Nausea/Vomiting	o
Constipation	o
Diarrhea	o

Lymph/Immune
Easy Bruising	o
Gums Bleed Easily	o
Enlarged Glands	o
Hay Fever/Allergies	o
Musculoskeletal
Joint Pain.Swelling	o
Back Pain	o
Muscle Pain	o

Difficulty Swallowing	o

Skin

Ears,Nose,Throat
Difficulty Hearing	o

Abdominal Pain Black Stools
•	
Rash/Sores	o
•	Abnormal Moles	o
•	
Ringing in Ears
•	
Abnormal Masses	o
•	
Vertigo	o
Sinus Pain	o
Nasal Congestion	o Frequent Sore Throats o Hoarseness	o

Cardiovascular
Chest Pain	o
Palpitations	o
Fainting Spells	o
Dizziness	o
Difficulty Lying Flat         o
Swelling in Legs	o
Cramps, Coldness in Legs  o

Genitourinary
Frequent Urination	o
Difficult Urination	o Burning on Urination o Nightime Frequency o Blood in Urine	o Abnormal Discharge o Genital Skin Lesions         o

Endocrine
Loss of Hair	o Heat/Cold Intolerance o Weight Gain	o
Sexual Dysfunction         o

Neurological Weakness/Paralysis	o Numbness	o
Tremors	o
Memory Loss	o

Psychiatric
Mood Swings	o
Difficulty Sleeping	o
Anxiety/Depression	o

W omen
Vaginal discharge or infections Painful intercourse or sexual difficulty Abnormal bleeding
Do you douche vaginally?

o
o
o
•	If so, how often  	
•	
Breast lump, pain or nipple discharge	o
History of abnormal Pap Smears	o

Date of first day of last menstrual period? Age at first period?

Age at menopause?

Number of days of menstrual flow per cycle?

Flow (check one)	o Mild    o Moderate   o Heavy Number of days between successive periods?
Number of pregnancies?   	
Number of Children?  	
History of female surgeries:	o Hysterectomy  o Tubes Tied o D&C o Other  	

MEN
Discharge from penis	o
Lump or pain in testicles	o
Problems with erections	o
Decreased sex drive/desire	o
Difficulty with urine stream	o

Please list recent past physicians with address and specialty who have cared for you:

1.     	

2.     	

3.     	

Who completed this form?	Patient  	

Relative  	

If so, what relationship?   	

Friend  	

 
Patient Signature	Date

THANK YOU for completing this 6 page Health History.  It will help us provide YOU with better care.

Do not write below this line

I reviewed this patient’s history form.

 	
Health Care Provider’s Signature	Date