Walgreens.

com/Clinic ∙ 855-WALGREENS (855-925-4733)

HEALTH HISTORY FORM

Patient Information
Name: Home Phone Number:

Address: Cell Phone Number:

Primary Care Provider Information

Name:
Address:

Phone Number:
Fax Number:

Specialty Care Provider Information

Provider Last Visit Date Practice Name/Address Phone Fax Number
Name/Specialty (Approximate) Number

©2013 Take Care Health Systems. All rights reserved.

Allergies
Food/Medication/Environmental Reaction (e.g. rash, hives, facial swelling)
Allergy

Medications (inhalers, eye/ear drops, supplements)

Alternatively, request a list of your medications from your pharmacy and bring it to the visit.

Medication Name Frequency Dose Route (oral, Condition for which

inhaled, injection) Medication is Prescribed

©2013 Take Care Health Systems. All rights reserved.

Past Medical History (Please check all that apply)
 No past medical history
Eyes/Ears Neurological Heart
 Glaucoma  Stroke  Heart Disease
 Problems with vision  Paralysis  Irregular Heart Rhythm
 Problems with hearing  Quadriplegia  Atrial Fibrillation
 Vertigo (dizziness)  Paraplegia  High Blood Pressure
 Hemiplegia  High Cholesterol
 Seizure Disorder (not on meds)  Heart Failure
 Epilepsy (currently on meds)  Angina (chest pain
 Alzheimer’s related to heart)
 Syncope or unexplained loss of
consciousness
 Dementia
 Schizophrenia
 Depression
 Cerebral Palsy
 Multiple Sclerosis
 Parkinson’s

Lungs Endocrine Cancer

 COPD (Chronic Obstructive  Diabetes  Lung Cancer
Pulmonary Disease)  Diabetes Type II  Liver Cancer
 Oxygen Therapy  Diabetes Type I  Colon Cancer
 Emphysema  Pre-Diabetes  Skin Cancer
 Obstructive Sleep Apnea  Hyperparathyroidism  Lymphoma/Bone
 Home BiPap/CPAP  Hypothyroidism Marrow Cancer
 Asthma (493.9)  Hyperthyroidism  Leukemia
 Chronic Bronchitis (491.9)  Hodgkin’s
 Cystic Fibrosis (277.00)  Prostate Cancer
 Currently with Tracheostomy(v44.0)  Breast Cancer
 Ovarian Cancer
 Uterine Cancer
 Other Cancer

Liver/Pancreas/Kidney Gastrointestinal Skin/Circulatory

 Liver Disease/Disorder  Colon Polyps  Skin Sore or Ulcer
 Hepatitis  Inflammatory Bowel Disease  Decubitis Ulcer
 Cirrhosis  Ulcerative Colitis (pressure ulcer)
 Chronic Pancreatitis  Crohn’s Disease  Peripheral Vascular
 Celiac Disease (gluten sensitivity)  Peptic Ulcer Disease Disease
 Kidney Disease or Renal Failure  Artificial opening for feeding or  Non-healing wounds or
 Receiving Dialysis elimination discoloration of leg
 Abnormal loss of weight

©2013 Take Care Health Systems. All rights reserved.

Blood & Bone Gender Specific:
 Blood Disorder Male
 Hemophilia or other clotting  Benign prostatic hypertrophy
disorder
 Multiple Myeloma Female
 HIV Positive asymptomatic  Taken birth control for 5 or more years
 HIV Positive symptomatic  Delivered a baby weighing more than 9 pounds
 Osteoporosis or low bone mass -  Gestational Diabetes
Receiving osteoporosis drug  Exposed to DES (diethylstilbestrol) prior to birth
therapy?  Fewer than 3 negative Pap tests
 Yes  No  Early onset of sexual activity (under 16 years of age)
 Vertebral Fracture(s)  Five or more sexual partners within a lifetime
 Hip Fracture(s)  History of a sexually transmitted disease (including HPV and/or
 Receiving oral steroid medications Human Immunodeficiency Virus [HIV])
(e.g. Prednisone) for more than 3
months
 SLE (Lupus)
 Systemic Sclerosis
 Sjogren’s
 Rheumatoid Arthritis
 Osteomyelitis (currently being
treated)
 Acute Osteomyelitis
 Chronic Osteomyelitis
 Bone Infection (currently being
treated)
 Sickle Cell Disease

Additional Past Medical History:

©2013 Take Care Health Systems. All rights reserved.

Vaccination History
Date(s) (if known)
Received ()
Vaccine Month/Year
Yes No Not
Sure
Pneumonia
Influenza (Flu shot)
Tdap (Tetanus, Diphtheria, Pertussis)
Td (Tetanus)
Zostavax (Shingles)
Hepatitis B (3 shot series)

©2013 Take Care Health Systems. All rights reserved.

Health Screening History
Received Screening Date Results () (if
() (if known)
know
n)
Mont
Type of Not h/Yea Abnorm If “Abnormal”,
Screening Test Screening Yes No Sure r Normal al briefly describe:
HIV HIV/AIDS
Fasting Blood Diabetes
Glucose or Glucose
Tolerance Test
Fasting Lipid Profile Cholesterol
Prostate Specific Prostate
Antigen (PSA) Cancer
Digital Rectal Exam Prostate
(DRE) Cancer
Colonoscopy Colon Cancer
Fecal Occult Blood Colon Cancer
Flexible Colon Cancer
Sigmoidoscopy
Barium Enema Colon Cancer
Mammogram Breast Cancer
Pap/Pelvic Cervical
Cancer
Bone Mass Density Osteoporosis
Glaucoma Vision
Dilated Retinal Exam Vision
Dental Exam Dental
Spirometry Test Pulmonary
If diagnosed with Diabetic
diabetes: Comprehensi
Monofilament Test ve Foot Exam

Past Surgical/Interventional History (Please check all that apply)

 Cataract removal  Heart surgery Joint replacement surgery
 Cochlear implant  Organ transplant  Shoulder
 Back surgery  Splenectomy  Hip
 Gall bladder removal  Other ____________________  Knee
6

©2013 Take Care Health Systems. All rights reserved.

Hospitalizations, Major Illnesses or Injuries
Date Briefly describe the major illness, injury and/or reason for
Type
(Month/Year) hospitalization
 Hospitalization
 Major Illness
 Injury
 Hospitalization
 Major Illness
 Injury
 Hospitalization
 Major Illness
 Injury
 Hospitalization
 Major Illness
 Injury
 Hospitalization
 Major Illness
 Injury
 Hospitalization
 Major Illness
 Injury

End-of-Life Planning
End-of-Life Planning consists of a legal document (e.g. Living Will, Advanced Directive) that explains your wishes
should you become incapacitated and unable to express your wishes regarding life-saving/sustaining medical
interventions.

Have you established a Living Will or Advanced Directive?  Yes  No

If you answered “No”, would you like more information

regarding obtaining end-of-life planning?  Yes  No

If you answered “Yes”, do you feel that your Primary

Care Physician is willing to follow your wishes as
expressed in the Living Will or Advanced Directive?  Yes  No

©2011 Take Care Health Systems. All rights reserved.

Review of Systems - Recent Medical History (Genitourinary) (Please check all that apply)
The questions in this section are asked to determine whether a chaperone will be needed for your visit.

In the past six to eight months, have you experienced any of the following?

 No recent medical history (genitourinary)

 Lump or bump in groin area  Change in breast size or shape

 Pain or aching sensation in groin area  Nipple discharge
 Discomfort or pain in groin area when lifting heavy  New or change in breast lump(s) or masses
objects (>10 lbs)  Breast pain

Other health problems or concerns: ______________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Home Safety Assessment: How well does your home meet your needs?
Place a “√” in the box to indicate “Yes” or “No” to each of the following questions:
Steps/Stairways or Walkways Yes No
Are they in good shape?
Do they have a smooth, safe surface?
Are there handrails on both sides of the stairway?
Do you have light switches at the top and bottom of the stairs?
Is there grasping space for both knuckles and fingers on the railings?
Are the stair treads deep enough for your whole foot?
Would there be room enough to install a ramp in any of these areas if it became necessary?
Floor Surfaces Yes No
Are floor surfaces safe?
Are they nonslip?
Are throw rugs or doormats placed so that they will not slip underfoot?
Is carpeting firmly placed and free from tears?
If there are floor level changes, are they obvious and/or well-marked?
Are electric, telephone, or extension cords placed so that you do not have to step over them?
Driveway and Garage Yes No

©2011 Take Care Health Systems. All rights reserved.

 Is there always space to park?
Is it convenient to the entrance?
Does the garage door open automatically?
Window and Doors Yes No
Are windows and doors easy to operate?
Do doorways accommodate a walker or wheelchair?
Can you walk through the doorways easily?
Is there space to maneuver while opening and closing doors?
Does the front door have a view panel or peephole at the right height?
Appliances/Kitchen/Bath Yes No
Is the room arranged safely and conveniently?
Do the oven and fridge open easily?
Are stove controls clearly marked and easy to use?
Is the counter the right height and depth?
Can you work sitting down?
Are cabinet doorknobs easy to use?
Are faucets easy to use?
Do you have a hand-held shower head?
Are the items you use often within reach on shelves?
Do you have a step stool with handles?
Can you easily get in and out of the tub or shower?
Do you have a bath or shower seat?
Are there grab bars where needed?
Is the hot water heater regulated to prevent scalding or burning?
Lighting/Ventilation Yes No
Are there enough lights, and are they bright enough?
Do you have night lights where needed?
Is area well ventilated?
Electrical Outlets/Switches/Alarms Yes No
Can you easily turn switches on and off?
Are outlets properly grounded to prevent a shock?
Are extension cords in good shape?
Do you have smoke detectors in all key areas?
Do you have an alarm system?
Is the telephone readily available for emergencies?
Does the telephone have a volume control?
Can you hear the doorbell ring all throughout the house?

Patient care services provided by Take Care Health Services, an independently owned corporation whose licensed healthcare
professionals are not employed by or agents of Walgreen Co., or its subsidiaries, including Take Care Health Systems LLC.
Walgreen Co. and its subsidiary companies provide management services to in-store clinics and worksite health and wellness
centers.

©2011 Take Care Health Systems. All rights reserved.