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Medical History
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Past Medical History
• • •
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Comments
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Past Surgical History
• • •
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Comments:
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Have you been hospitalized within the past 6 months?
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Reason
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Discharge Date
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Immunizations?
• • •
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Comments
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Are you under a doctor's care at this time?
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PCP
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Do you see any specialists?
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Name and Type of Specialist
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Family History
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Father's Medical Hx
• • •
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Comments
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Mother's Medical Hx
• • •
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Comments
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Sibling(s)' Medical Hx
• • •
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Comments
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Social History
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N/A - Pediatric patient
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Marital Status
• • •
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Living Arrangements
• • •
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Occupation
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Employer
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Caffeine
• • •
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Type of Caffeine?
• • •
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Alcohol
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Type of alcohol
• • •
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Drug use?
• • •
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Type of drug?
• • •
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Tobacco?
• • •
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Type of Tobacco
• • •
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Sexually active?
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Uses Protection?
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GYN History
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Number of pregnancies
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Type of Deliveries
• • •
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Living children?
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Abortions?
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Miscarriages?
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Last Menstrual Period
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Post menopausal?
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Comments
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Birth Control
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Type of Birth Control
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Depression Screening
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Little interest/pleasure in doing things?
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Feeling down, depressed, or hopeless?
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Trouble falling or staying asleep, or sleeping too much?
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Feeling tired or having little energy?
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Poor appetite or overeating?
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Feeling bad about yourself or that you're a failure or have let your family down?
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Trouble concentrating, such as reading newspaper or watching TV?
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Moving or speaking so slowly or fidgeting more than usual that others have noticed?
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Thoughts that you would be better of dead or want to hurt yourself?
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Do your symptoms make it hard to do your work, care for things at home, or get along with other people?
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PHQ-9 Total
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Depression Category
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