Health Maintenance – Prescreening

To help our doctors understand you better and to give you more time to gather your past medical history, please fill in the following form before your exam

MAKE AN APPOINTMENT

Doctor giving the Annual Health Exam*
Name*
First Last
Email*
Date of upcoming exam
MM slash DD slash YYYY
Time

: Hours

Minutes

AM/PM
Patient status*
- Existing patient with previous Health Maintenance exam at FirstMed
- Existing patient - First Health Maintenance exam
- New patient
Sex*
- Male
- Female
Current age*
Past exams
For the following types of exams, please advise when you were last examined. If you recall the month and year then YY/MM, if only the year then YYYY, otherwise write to the best of your recollection (e.g., about 5 years ago).
Last annual health examination
(MM/YY) if known.
Last annual gynecological exam
Last Pap smear
Age at first menstrual period (FMP)
Start of last menstrual period (LMP)
Date
MM slash DD slash YYYY
Number of pregnancies (Gravitas)
Number of births
Number of missed abortions / miscarriages
A missed abortion is a nonviable intrauterine pregnancy that has been retained within the uterus without spontaneous abortion.
Number of planned terminations
Date of hysterectomy
removal of the uterus - (when applicable)
Date of oophorectomy
removal of one or both ovaries - (when applicable)
Last mammogram
Bone densitometry screening
DEXA or Osteodensitometry (ODM)
Last prostate screening
Last chest x-ray
Last colonoscopy
Current Medical
For the following questions, if you need to list 2 or more items, please start each entry on a new line starting with a hyphen (-) and space. See the example above (Current medications)
Known allergies
Please list your allergies. For each one, begin a new line starting with a hyphen (-) and space, then type of allergy, severity, and anything else relevant. (See the example above 'Known allergies')
Current medications (including non-prescribed)
Please list all the medications, supplements, and vitamins. Using separate lines, list medication / active drug name, dosage and frequency, and reason for taking.
Adverse medication reactions
Please list medications you have had past adverse medical reactions; each on separate lines starting with '-'
Past Medical
Past surgical procedures and significant medical illnesses
List the significant medical events separately, starting each line with hyphen and space, followed by the illness or procedure, the year, and anything of note. Example above
Any current medical complaints?
Please describe current issues you'd like the doctor to know about, e.g. -Frequent headaches.
Immunization History
Please list the dates of either vaccinations or illnesses related to the following diseases. The format should be YYYY, then either "vax" when vaccinated, or "ill". Write "none" if neither, or comment to explain (for example, "I believe I had rubella as a child")
MMR vaccination / illness
(Measles, mumps, and rubella) Please note Vax or illness
Varicella / chickenpox; vaccination or illness
-Chickenpox, ill, 2013
Last influenza vaccination
Year of last Flu Shot, or 'none'.
Last tetanus booster
Year of last tetanus booster if known.
Hepatitis A vaccination
Hepatitis B vaccination
Last FSME (Tick-borne encephalitis)
COVID19 (Illness or vaccination)
Date of last illness or vaccination with brand, number of doses, side effects.
Additional vaccinations
Aside from the vaccinations mentioned above, can you report any other vaccinations?
Family History
Please provide any chronical illness suffered by a blood relative that could be considered congenital, and if deceased use this format: -Heart Disease, then new line, -deceased, 74, Stroke
Mother
Father
Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather
Sibling congenital illness starting with a '-'
Please separate on lines
Children's serious illness
Please use a separate line for each child
Social History
Please provide details regarding your current lifestyle
Marital status
Children
ages
Occupation
Nutrition
How would you describe the nutrition of your average meal?
Tobacco use
If smoking, how many cigarettes in a week?
Alcohol use
How much do you drink in a week?
Caffeine use
What and how much do you drink daily?
Exercise
Active minutes of exercise per week.

Please use the following formats when entering in data

Past exams

Last annual health examination

e.g.: 12/2017 or 2017

Known allergies

-Bee Stings
-Advil, EPI pen

Current medications

-Jethrix, 3x day
-Riladol, 1x day, as needed

Past surgical procedures and significant medical illnesses

-Appendicitis, 1988
-Pneumonia, 2018, hospitalization 2 weeks

Family history

Mother:

-COPD
-deceased, 74, lung cancer

Sibling congenital history

-Brother, deceased, 22, rectal cancer
-Sister, illness, 42, breast cancer

Health Maintenance – Prescreening

Past exams

Current Medical

Past Medical

Immunization History

Family History

Social History

Please use the following formats when entering in data

Past exams

Last annual health examination

Known allergies

Current medications

Past surgical procedures and significant medical illnesses

Family history

Sibling congenital history

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