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Has the form been printed?
By selecting PURGE (Delete Record) , the record is moved off of region reports and will be deleted after 90 days.
Selecting 'Yes' and saving the record will remove this record from the County report. All records can still be found via Add/Edit Records search. Resources: Quick Tip , User Guide
Form printed?
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Yes No PURGE (Delete Record)
Purge Reason
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Duplicate Incomplete Not Needed Testing
PATIENT HEALTH HISTORY FORM
Patient Name: Date of Birth: Health Department: (Where you have your appointment.)
Patient Name: ______ Date of Birth: ______ Health Dept: ______ Language: ______
Patient Name
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Patient DOB
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Today M-D-Y
Health Department
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Anderson Bedford Benton Bledsoe Blount Bradley Campbell Cannon Carroll Carter Cheatham Chester Claiborne Clay Cocke Coffee Crockett Cumberland Decatur DeKalb Dickson Dickson - White Bluff Dyer Fayette Fentress Franklin Gibson - Humboldt Gibson - Milan Gibson - Trenton Giles Grainger Greene Grundy Hamblen Hancock Hardeman Hardin Hawkins - Church Hill Hawkins - Rogersville Haywood Henderson Henry Hickman Houston Humphreys Jackson Jefferson Johnson Lake Lauderdale Lawrence Lewis Lincoln Loudon Macon Madison Marion Marshall Maury McMinn McNairy Meigs Monroe Montgomery Moore Morgan Obion Overton Perry Pickett Polk - Benton Polk - Copper Hill Putnam Rhea Roane Robertson Rutherford - Murfreesboro Rutherford - Smyrna Scott Sequatchie Sevier Smith Stewart Sullivan - Blountville Sullivan - Kingsport Sumner - Gallatin Sumner - Hendersonville Sumner - Portland Tipton Trousdale Unicoi Union Van Buren Warren Washington Wayne Weakley White Williamson - Fairview Williamson - Franklin Wilson
Reason for Visit: {pt_rfv
How many allergies do you have? (Medications, Food, Latex, Bee Stings, etc.)
Allergies Reported
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None 1 2 3 4+
ALLERGIES (Medication, Food, Latex, Bee Stings, etc.) TYPE OF REACTION Pt responded they do NOT have allergies.
ALLERGIES (Medication, Food, Latex, Bee Stings, etc.) TYPE OF REACTION Pt responded they have 4 or more allergies. Three are listed below and others will be discussed in clinic.
ALLERGIES (Medication, Food, Latex, Bee Stings, etc.) TYPE OF REACTION
______ ______ ______ ______ ______ ______
How many medications are you taking? (Prescriptions, Over the Counter, and/or Supplements)
Medications Reported
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None 1 2 3 4 5 6 7 8+
MEDICATIONS PLEASE BRING MEDICATIONS IN BOTTLES WITH YOU TO THE CLINIC Prescriptions, Over the Counter, and Supplements
How Much / How Often Reason
MEDICATIONS PLEASE BRING MEDICATIONS IN BOTTLES WITH YOU TO THE CLINIC. Prescriptions, Over the Counter, and Supplements
How Much / How Often Reason Pt responded they are taking 8 or more medications. Seven are listed below and others will be discussed in clinc.
MEDICATIONS Prescriptions, Over the Counter, and Supplements
How Much / How Often Reason Pt responded they do NOT currently take any medications.
______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______
Medication 01 - Quantity / Frequency
Medication 02 - Quantity / Frequency
Medication 03 - Quantity / Frequency
Medication 04 - Quantity / Frequency
Medication 05 - Quantity / Frequency
Medication 06 - Quantity / Frequency
Medication 07 - Quantity / Frequency
PHYSICIANS AND PHARMACIES Pharmacy: Address: Phone/Fax: Primary Care Provider: Address: Phone/Fax: Specialist: Address: Phone/Fax: Specialist: Address: Phone/Fax:
PHYSICIANS AND PHARMACIES Pharmacy Address Phone / Fax {pharm_01 {pharm_01_address {pharm_01_phone Primary Care Provider & Specialist(s) Address Phone/Fax {pcp_01 {pcp_01_address {pcp_01_phone {pcp_02 {pcp_02_address {pcp_02_phone {pcp_03 {pcp_03_address {pcp_03_phone
PHYSICIANS AND PHARMACIES Pharmacy Address Phone / Fax ______ ______ ______ Primary Care Provider & Specialist(s) Address Phone/Fax ______ ______ ______ ______ ______ ______ ______ ______ ______
PCP / Specialist 01 - Address
PCP / Specialist 01 - Phone/Fax
PCP / Specialist 02 - Address
PCP / Specialist 02 - Phone/Fax
PCP / Specialist 03 - Address
PCP / Specialist 03 - Phone/Fax
PHQ-2 Do you have little interest or pleasure doing things?Have you been feeling down, depressed, or hopeless? ______ ______
Score of 3 or more is considered positive. ______
PHQ-2 Do you have little interest or pleasure in doing things? Have you been feeling down, depressed, or hopeless?
Not at all Several days More than 1/2 the days Nearly every day
Feeling down, depressed, hopeless
Not at all Several days More than 1/2 the days Nearly every day
View equation SOCIAL DETERMINANTS OF HEALTH ______ In the last 12 months, felt worried that food would run out before you got money to buy more? ______ In the last 12 months, has your utility company shut off your service for not paying your bills? ______ Do you think you are at risk of becoming homeless? ______ Do you have trouble taking care of a child or family member? ______ In the last 12 months, has lack of transportation kept from medical appts or getting meds? ______ Does anyone in your life hurt, threaten, frighten or make you feel unsafe? ______ Are you currently unemployed? ______ Do you have trouble paying for medications? ______ Are you currently receiving support from a case manager / social worker for needs? ______ If you answered YES to any above, would you like to receive assistance? ______ Do you have urgent needs? (no food tonight, no place to sleep tonight, fear may harm self)
SOCIAL DETERMINANTS OF HEALTH (check as applies) In the last 12 months, have you worried that your food would run out before you got money to buy more? In the last 12 months, has your utility company shut off your service for not paying your bills? Do you think you are at risk of becoming homeless? Do you have trouble taking care of a child or family member? In the last 12 months, has lack of transportation kept you from medical appointments or getting your medications? Does anyone in your life hurt you, threaten you, frighten you or make you feel unsafe? Are you currently unemployed? Do you have trouble paying for medications? Are you currently receiving support from a case manager or social worker for your healthcare or social needs? Do you have urgent needs? For example: I don't have food tonight. I don't have a place to sleep tonight. I fear I may harm myself.
Would you like to receive assistance with any of these needs?
Trouble caring child/family
ALCOHOL, TOBACCO, VAPE, AND RECREATIONAL DRUGS Do you drink alcohol? Do you use tobacco products? Do you use recreational drugs? ______ ______ ______
Are you interested in assistance with quitting alcohol, tobacco, or drugs? ______
ALCOHOL, TOBACCO, VAPE, AND RECREATIONAL DRUGS Do you drink alcohol? Do you use tobacco products ? Do you use recreational drugs ?
Are you interested in assistance with quitting alcohol, tobacco, or drugs?
Never
Sometimes
Often
Previous Use
Prefer not to disclose.
Never
Sometimes
Often
Previous Use
Prefer not to disclose.
Never
Sometimes
Often
Previous Use
Prefer not to disclose.
Assistance with Quitting Substance Use
Yes No
SCREENING TESTS Select all screenings you've had and enter date of last screening test if known. ______ ______ ______ ______ ______ ______ ______ ______ ______ ______
SCREENING TESTS Select all screenings you've had and enter date of last screening test if known.
SURGERIES / HOSPITALIZATIONS / INJURIES ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______
SURGERIES / HOSPITALIZATIONS / INJURIES
Other Surgery / Hospitalization / Injury
Other Surgery / Hospitalization / Injury TYPE
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Do you have any medical history to report? (Have or take medications for conditions)
Pt Medical Report
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YES, I have medical history to report.
NO, I do NOT have any medical history to report at this time.
MEDICAL HISTORY -- I have or take medications for the following: Cardiovascular Gastrointestinal Respiratory Genitourinary ______ ______ ______ ______ Skin Head/Eyes/Ears/Nose/Throat Musculoskeletal Neurologic ______ ______ ______ ______ Endocrine Psychiatric Infectious Cancer ______ ______ ______ ______ ______ OTHER ______ ______
MEDICAL HISTORY -- I have or take medications for the following: Cardiovascular Gastrointestinal ______ ______ Respiratory Genitourinary ______ ______ Skin Head/Eyes/Ears/Nose/Throat ______ ______ Musculoskeletal Neurologic ______ ______ Endocrine Psychiatric ______ ______ Infectious Cancer ______ ______ ______ OTHER ______ ______
MEDICAL HISTORY -- I have or take medications for the following: Cardiovascular Gastrointestinal Respiratory Genitourinary Skin Head/Eyes/Ears/Nose/Throat Musculoskeletal Neurologic Endocrine Psychiatric Infectious Cancer OTHER
MEDICAL HISTORY Pt responded they do NOT have any medical history to report.
Head/Eyes/Ears/Nose/Throat
OTHER Cancer Type
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OTHER Medical Type
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Do you have any FAMILY medical history to report? EX: Mother, Father, Sibling(s), Child(ren)
YES, I have family medical history to report.
NO, I do NOT have any family medical history to report at this time.
Mother Father Sibling(s) Child(ren) ______ ______ ______ ______
Mother Father Sibling(s) Child(ren)
ADVANCE DIRECTIVE FOR HEALTHCARE (Age 18 and above ONLY) Example: Living Will, Durable Power of Attorney, Organ Donation, "Do Not Resuscitate" Instructions Have you finalized any advance health directives? IF NO to previous question, would you like information?
ADVANCE DIRECTIVE FOR HEALTHCARE (Age 18 and above ONLY) Have you finalized any advance health directives? ______ IF NO to previous question, would you like information? ______
Finalized Advance Directive
Yes No
Advance Directive Info Desired
Yes No
Now M-D-Y H:M