Earthly Balance Perinatal Care
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New Patient’s Information Sheet
Medical History Form
Authorization Form
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Home
About Us
Services
Contact Us
Referral Form
Form
New Patient’s Information Sheet
Medical History Form
Authorization Form
(808) 646-3782
Contact Us
Medical History Form
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Patient Name
*
Medication
Dose
Frequency
Allergy
Reaction or Side Affect
Multiple Choice
Myocardial Infarction (Heart Attack)
Hypertension (High Blood Pressure)
Diabetes
High Cholesterol
Congential Heart Disease
Please specify
Please specify:
Multiple Choice
Stroke
Coagulation (Bleeding/Clotting)
Depression/Suicide Attempt
Alcoholism
Cancer
Sexually transmitted infections
Please specify
Single Line Text
Hepatitis
A
B
C
Date of Last Colonoscopy
Other
Date of Last Tetanus Shot
Date of Last HIV Test
Date of Blood Transfusion
Current Mental Health Status
Stable
Unstable
Other
History of Inpatient Psychiatric Hospitalization
Mental Health Medication Name
Current Mental Health Provider
Mental Health Medication Dosage
Receiving Mental Health Therapy
Mental Health Medication Dosage Frequency
Any Other Mental Health Concerns
Surgery
Date
Hepatities A
Hepatities B
MMR
Measles
Pneumovax
Other
Mumps
Tdap
Rubella
Varicella
# of Pregnancies
# of Abortions
Any Previous Complications with Pregnancy/Birth
Age of 1st Menses
Length of menses
Date of last mammogram
Have you ever had an abnormal Pap Smear? (copy)
Yes
No
If you choose Yes, when it was?
Single Line Text
# of Deliveries
# of Miscarriages
Frequency of menses
Date of last menses
Do you have any concerns about your period or menopause?
Yes
No
Please Explain
Single Line Text
Mother
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
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
Single Line Text
Family History of Mental Illness
Father
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
Single Line Text
Paternal 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
Siblings
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
Single Line Text
Paternal Grandfather
Live
Asthma
Diabete
High Blood Pressure
Heart Disease
Stroke
Heart Attack
Cancer (Type)
Colon Polyps
Depression
Other
Other Family Member information
Single Line Text
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
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
EXERCISE: Do you exercise regularly?
Yes
No
Third Choice
Tabacco Use: Current Never Former Quit on
If current # of packs/day
# of Years
Other Tobacco: Pipe Cigar Snuff Chew Are you Interested In Quitting?
Yes
No
If yes, # of drinks per week:
What type of alcohol:
Drug Use: Do you use any recreational drugs?
Yes
No
If yes, Please list
If you have used in the past how long have you been drug free?
Have you ever used needles for IV drug use?
Yes
No
Alcohol: Do you exercise regularly?
Yes
No
Is alcohol a concern for you or others who surround themselves around you?
Yes
No
Do you wear a seat Belt Regularly
Yes
No
Do you feel safe in home?
Yes
No
Have you been physical of sexual Abuse?
Yes
No
Are you a member of a gang?
Yes
No
Do you wear a bike helmet regularly?
Yes
No
Do you feel safe in your current relationship?
Yes
No
Do you have gun in your home?
Yes
No
Occupation:
Marital Status:
Who lives at home with you?
Degree of education completed:
Spouse/Partner’s Name:
Are you sexually active?
Yes
No
If sexually active do you practice safe sex?
Yes
No
Other Concerns
Birth Control Method: Have you ever had a sexually transmitted diease?
Yes
No
Please Mental with
If Yes, Please Include:
Are you interested in being screened for sexually transmitted diseases?
Yes
No
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 felt depressed or sad much of the time in the past year?
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
Do you ever feel like hurting yourself of others?
Yes
No
Constitutional
Fevers/chills/sweats
Unexplained weight loss/gain
Fatigue/weakness
Excessive thirst or urination
Other:
Cardiovascular
Chest pain/discomfort
Leg pain with exercise
Heart murmur or heart problems
Palpitations
Other:
Chest
Breast lump/discharge
Other:
Ears/Nose/Throat/Mouth
Difficulty hearing/ringing in ears
Hay fever/allergies
Problems with teeth/gums
Difficulty swallowing
Difficulty with speech
Other
Endocrine
Hypothyroid
Hyperthyroid
Abnormal hormone levels
Abnormal blood glucose levels
Other
Signature of Authorizating Party
Eyes
Changes in vision
Farsighted
Nearsighted
Other:
Gastrointestinal
Abdominal pain
Blood in bowel movement
Nausea/vomiting/diarrhea
Other:
Genitourinary
Nighttime urination
Incontinence
Sexual function problems
Discharge from penis
Other:
Gynecological
Abnormal vaginal bleeding
Problems with conceiving
Problems with contraception
Vaginal discharge
Vaginal odor
Painful intercourse
Other:
Lymphatic/Blood
Unexplained lumps
Easy bruising/bleeding
Anemia
Other:
Musculo-skeletal
Muscle/joint pain
Arthritis
Other:
Neurological
Headaches
Dizziness/light-headedness
Numbness
Memory loss
Loss of coordination
Epilepsy or convulsive seizures
Other:
Psychiatric
Anxiety/stress
Problems with sleep
Depression
Suicidal ideations
Other:
Respiratory
Cough/wheeze
Difficulty breathing
Asthma
COPD
Sleep apnea
Other:
Skin
Rash or mole change(s
Psoriasis
Eczema
Other:
Submit
