Earthly Balance Perinatal Care
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New Patient’s Information Sheet
Medical History Form
Authorization Form
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Form
New Patient’s Information Sheet
Medical History Form
Authorization Form
317-647-6689
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Medical History Form
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Present Health Concerns
Today's Date
Patient Name
*
Date of Birth
MEDICATIONS: Please list all prescription and Non-Prescription medicines, vitamins, remedies, birth control pills, herbs etc
Medication
Dose
Frequency
ALLERGIES: List all reaction to medicines, foods and other agents
Allergy
Reaction or Side Affect
PERSONAL MEDICAL HISTORY: Please indicate whether you have had any of the following medical problems
Multiple Choice
Myocardial Infarction (Heart Attack)
Hypertension (High Blood Pressure)
Diabetes
High Cholesterol
Congential Heart Disease
Please specify
Multiple Choice
Stroke
Coagulation (Bleeding/Clotting)
Depression/Suicide Attempt
Alcoholism
Cancer
Sexually transmitted infections
Please specify
Hepatitis
A
B
C
Please specify:
Single Line Text
PERSONAL MEDICAL HISTORY: Please indicate whether you have had any of the following medical problems
Date of Last Colonoscopy
Date of Last Tetanus Shot
Date of Last HIV Test
Date of Blood Transfusion
Other
PERSONAL MENTAL HEALTH HISTORY: Please indicate whether you have had any of the following mental health problems
Current Mental Health Status
Stable
Unstable
Other
Mental Health Medication Name
Mental Health Medication Dosage
Mental Health Medication Dosage Frequency
History of Inpatient Psychiatric Hospitalization
Current Mental Health Provider
Receiving Mental Health Therapy
Any Other Mental Health Concerns
SURGICAL HISTORY: Please list all prior surgeries and dates
Surgery
Date
IMMUNIZATIONS: Please List your most recent immunizations, not including those administered at lowell General Hospital. Please include your best estimate of this month and year of each immunization.
Hepatities A
Measles
Mumps
Rubella
Hepatities B
Pneumovax
Tdap
Varicella
MMR
Other
WOMEN'S HEALTHY GYNECOLOGIC/OBSTETRIC HISTORY (For women only)
# of Pregnancies
# of Deliveries
# of Abortions
# of Miscarriages
Any Previous Complications with Pregnancy/Birth
Frequency of menses
Age of 1st Menses
Date of last menses
Length of menses
Do you have any concerns about your period or menopause?
Yes
No
Please Explain
Date of last mammogram
Single Line Text
Have you ever had an abnormal Pap Smear? (copy)
Yes
No
If you choose Yes, when it was?
Date of Last Pap Smear
Single Line Text
FAMILY HISTORY: Please indicate with a check (√) who in your family has had the following conditions. In the first column please indicate their living status. L = Living, D = Deceased, U = Unknown.
Mother
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
Father
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
Siblings
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
Maternal Grandmother
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
Single Line Text
Single Line Text
Single Line Text
Single Line Text
Maternal Grandfather
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
Paternal Grandmother
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
Paternal Grandfather
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
Other
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
Single Line Text
Single Line Text
Single Line Text
Single Line Text
Family History of Mental Illness
SOCIAL HISTORY
EXERCISE: Do you exercise regularly?
Yes
No
Third Choice
Drug Use: Do you use any recreational drugs?
Yes
No
Tabacco Use: Current Never Former Quit on
If yes, Please list
If current # of packs/day
If you have used in the past how long have you been drug free?
# of Years
Have you ever used needles for IV drug use?
Yes
No
Other Tobacco: Pipe Cigar Snuff Chew Are you Interested In Quitting?
Yes
No
Alcohol: Do you exercise regularly?
Yes
No
If yes, # of drinks per week:
Is alcohol a concern for you or others who surround themselves around you?
Yes
No
What type of alcohol:
interest have gang?
Safety
Do you wear a seat Belt Regularly
Yes
No
Do you wear a bike helmet regularly?
Yes
No
Do you feel safe in home?
Yes
No
Do you feel safe in your current relationship?
Yes
No
Have you been physical of sexual Abuse?
Yes
No
Do you have gun in your home?
Yes
No
Are you a member of a gang?
Yes
No
SOCIOECONOMIC
Occupation:
Degree of education completed:
Marital Status:
Spouse/Partner’s Name:
Who lives at home with you?
SEXUALITY
Are you sexually active?
Yes
No
Birth Control Method: Have you ever had a sexually transmitted diease?
Yes
No
If sexually active do you practice safe sex?
Yes
No
If Yes, Please Include:
Other Concerns
Are you interested in being screened for sexually transmitted diseases?
Yes
No
Emotions
In the past year, have you had 2 or more weeks during which you felt sad or depressed; or you lost all interest or pleasure in things that you usually cared about or enjoyed?
Yes
No
Have you had 2 or more years in your life when you felt depressed or sad most days, even if you felt okay sometimes?
Yes
No
Have you felt depressed or sad much of the time in the past year?
Yes
No
Do you ever feel like hurting yourself of others?
Yes
No
REVIEW OF SYSTEMS: Please indicate with a check (√) any current problems you have below.
Constitutional
Fevers/chills/sweats
Unexplained weight loss/gain
Fatigue/weakness
Excessive thirst or urination
Other:
Eyes
Changes in vision
Farsighted
Nearsighted
Other:
Musculo-skeletal
Muscle/joint pain
Arthritis
Other:
Cardiovascular
Chest pain/discomfort
Leg pain with exercise
Heart murmur or heart problems
Palpitations
Other:
Gastrointestinal
Abdominal pain
Blood in bowel movement
Nausea/vomiting/diarrhea
Other:
Neurological
Headaches
Dizziness/light-headedness
Numbness
Memory loss
Loss of coordination
Epilepsy or convulsive seizures
Other:
Chest
Breast lump/discharge
Other:
Genitourinary
Nighttime urination
Incontinence
Sexual function problems
Discharge from penis
Other:
Psychiatric
Anxiety/stress
Problems with sleep
Depression
Suicidal ideations
Other:
Ears/Nose/Throat/Mouth
Difficulty hearing/ringing in ears
Hay fever/allergies
Problems with teeth/gums
Difficulty swallowing
Difficulty with speech
Other
Gynecological
Abnormal vaginal bleeding
Problems with conceiving
Problems with contraception
Vaginal discharge
Vaginal odor
Painful intercourse
Other:
Respiratory
Cough/wheeze
Difficulty breathing
Asthma
COPD
Sleep apnea
Other:
Endocrine
Hypothyroid
Hyperthyroid
Abnormal hormone levels
Abnormal blood glucose levels
Other
Lymphatic/Blood
Unexplained lumps
Easy bruising/bleeding
Anemia
Other:
Skin
Rash or mole change(s
Psoriasis
Eczema
Other:
Signature of Authorizating Party
Today's Date
Submit
