Patient Identification

MERCY HOSPITAL
144 STATE STREET PORTLAND ME 04101

Mercy Primary Care Department

CONFIDENTIAL HISTORY
Date________________

Last Name First Middle Birth Date

If Living If Deceased
FAMILY
Sex Age Health Age at Cause
HISTORY: Death
Father
Mother
Brothers/Sister* (Circle Sex)
M F
M F
M F
M F
M F
Husband/Wife
Sons/Daughters* (Circle Sex)
M F
M F
M F
M F
M F

*Since some names may be used for either men or women, please circle sex for each Brother, Sister, Son or Daughter.

Do you know of a blood relative who has or had: (Circle and give relationship)
Heart Attack or Breast Cancer Eczema Mental
Heart Failure Illness

Stroke Uterus or Tuberculosis Stomach

Cervical Cancer Ulcers

High Blood Pressure Leukemia Seizures/ Colitis

Epilepsy

Diabetes Other Cancer Migraine Rheumatoid

Arthritis

Kidney Disease Asthma Suicide Glaucoma

Colon Cancer Hay Fever Nervous Blindness or

Breakdown Near Blindness

Alcoholism Malignant Moles Cystic Fibrosis

MMA 11 03/07/2018 Page 1 of 4

 Patient Identification

MERCY HOSPITAL
144 STATE STREET, PORTLAND, ME 04101

Mercy Primary Care Department

Personal History: 3. How many cups of caffeine do you drink per day?

1. Please describe your smoking habits: coffee, tea, soda:___________________________

cigarettes cigars pipe chew

year started_______ packs per day______

year quit _______ never ______
4. Describe what kind of exercise you do:
2. How man alcoholic drinks do you have? (beer, wine,
liquor)

per day ___________ on a weekend______

at a social event______ never _____

5. Name any illnesses, conditions, diseases or diagnosis that you have or have had:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

6. Serious injuries:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

7. All operations or surgeries:

_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

8. Any other hospitalizations and the reasons for them: Also include dates:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

9. List all medications (please include aspirin, Tylenol, cold remedies, vitamins or supplements, tranquillizers, weight reducers,
birth control pills, laxatives):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

10. Allergies (name any drugs or food to which you are allergic):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

MMA 11 03/07/18; 10/23/18 Page 2 of 4

 Patient Identification

MERCY HOSPITAL
144 STATE STREET, PORTLAND, ME 04101

Mercy Primary Care Department

REVIEW OF SYSTEMS: Please check the adjacent box if you have had any of the conditions or problems mentioned below
Chronic Fatigue Diabetes
Recent weight loss Thyroid Disease
Anemia Cancer
Bruise easily Recent loss of appetite
Sleeping difficulties
Frequent Headaches Nervousness
Convulsions/seizures Depression
Stroke Memory loss
Tremor hands shaking Phobias
Numbness/tingling sensations Mental Illness
Dizzy spells/fainting
Ringing in the ears Recurrent nosebleeds
Frequent ear infections Sinus trouble
Failing hearing Frequent sore throats
Failing vision Prolonged hoarseness
Double or blurred vision Difficulty swallowing

Frequent respiratory infections Shortness of breath on exertion

Chronic cough/bronchitis Shortness of breath lying flat
Coughing up blood Hay Fever/allergies
Asthma/wheezing Tuberculosis
Chest Pain, tightness or squeezing High blood pressure
Palpitations Heart murmur
Irregular pulse Leg pain when walking
Swollen ankles Varicose veins/phlebitis

Indigestion/heartburn Diarrhea
Persistent nausea/vomiting Constipation
Peptic ulcers/chronic abdominal pain Bloody or tarry stools
Recent change in bowel habits Hemorrhoids
Ribbon or pencil like stools Gall bladder trouble
Diverticulosis Hepatitis/yellow jaundice
Frequent urine infections Decrease in force of urine stream
Painful urination Kidney stones
Blood in urine Venereal disease
Frequent rising at night to urinate Herpes
Difficulty in controlling urine Discharge from penis
Hernia

Arthritis/rheumatism Gout
Muscle weakness Cold numb feet or foot pain
Recurrent back pain

Rashes Hives
Eczema Reactions to foods, stings, etc.
Psoriasis Sores that won’t heal
Worrisome moles

Chicken pox Polio

Measles Scarlet Fever
German measles Rheumatic Fever
Last shot - tetanus Mumps
Last shot - Flu Did you realize all of your childhood immunizations
(shots)
Last shot - Pneumonia

MMA 11 03/07/18; 10/23/18 Page 3 of 4

 Patient Identification

MERCY HOSPITAL
144 STATE STREET, PORTLAND, ME 04101

Mercy Primary Care Department

FOR WOMEN
ONLY:
Age of first period___________________________________ ( ) Discharge from nipple or breast
Periods regular or irregular____________________________ ( ) Mother used DES
How many days between periods_______________________ Pain or cramps with periods: ( ) heavy ( ) moderate ( ) light
How long is each period______________________________ Blood flow with periods: ( ) heavy ( ) moderate ( ) light
Date of start of last menstrual period____________________ Pain or bleeding with intercourse_____________________________
Number of pregnancies______________________________ Have you gone or are you going through the change of life? Y/N
Complications:_______________________________ Date of last menses______________________________________
Number of live births________________________________
Complications________________________________
Number of miscarriages_______________________________
Complications_________________________________
Types of birth control used_____________________________
Type using now______________________________________

FOR MEN ONLY:

( ) Lumps in testicles
( ) Genital or prostate trouble
( ) Problems with sexual response

DESCRIBE BRIEFLY YOUR PROBLEM

_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

MMA 11 03/07/18; 10/23/18 Page 4 of 4