UI Prototype: Consumer's Health Summary Form
(version 2: 9 Oct 00)


 Patient Health Summary Form
 

The following extensive form asks important information regarding your health. This information will assist your healthcare provider(s) in administering the best possible healthcare. You can submit this information directly to your physician's office via WebMD Secure Messaging, a process that encrypts the text so that it cannot be read by anyone except the intended recipient. You can also print this form, fill it in and take it to your doctor's office.

Please answer to the best of your ability. The questions in this form are organized into the following sections. You can click on the titles to go directly to a specific section
   
 
 Personal and Emergency Information Return to Top  

Personal Information   
    Please enter your personal, address and contact information.
  First name:
  Middle Name:
  Last name:
  Gender: Female Male
  Date of birth: / / (mm/dd/yyyy)
     
  SSN: - -
    Please keep my Social Security Number private and do not display it when printing
  Age at time of visit:
  Street address1:
  Street address2:
  City:
  State:
  ZIP or postal code:
  Country:
  Home telephone: - -
  Work telephone: - -   Ext.
  Email address1:
  Email address2:
  Mobile telephone: - -
  Pager number: - -   PIN
Emergency (1) Contact Information Return to Top  
  In case there is an emergency, who should be contacted first?
  First Name:
  Last Name:
  Home telephone: - -
  Work telephone: - -   Ext.
  Mobile phone: - -
  Pager: - -   PIN
  Street address:
  City:
  State:
  ZIP or postal code:
  Country:
     
Emergency (2) Contact Information Return to Top  
  In case there is an emergency, and your first emergency contact can't be reached, who should be contacted next?
  First Name:
  Last Name:
  Home telephone: - -
  Work telephone: - -   Ext.
  Mobile phone: - -
  Pager: - -   PIN
  Street address:
  City:
  State:
  ZIP or postal code:
  Country:
     

 Healthcare Management Information Return to Top  

Healthcare Provider (1) Information  
  Please enter information about your current health care providers.
  First Name:
  Last Name:
  Telephones: - - Daytime
    - - Evening
    - - Emergency
  Title:
  Specialty:
    Check here if the doctor is your primary care physician.
  Street address1:
  Street address2:
  City:
  State:
  ZIP or postal code:
  Country:
  Email address:
     
Healthcare Provider (2) Information Return to Top  
  Please enter information about another current health care provider.
  First Name:
  Last Name:
  Telephones: - - Daytime
    - - Evening
    - - Emergency
  Provider Role:
  Provider Specialty:
     
  Street address1:
  Street address2:
  City:
  State:
  ZIP or postal code:
  Country:
  Email address:
     
Primary Health Insurance Return to Top  
  Please enter your primary health insurance information.
     
  Name of insured: First name
    Middle Name
    Last name
  Employer:
  Primary health plan:
  Group Number:
  Member ID:
Secondary Health Insurance Return to Top  
  Please enter your secondary health insurance information.
     
  Name of insured: First name
    Middle Name
    Last name
  Employer:
  2nd health plan:
  Group Number:
  Member ID:
Pharmacy (1) Information Return to Top  
  Please enter information about any employer sponsored health plans or personal health plans for which the patient is the primary beneficiary.
  Pharmacy:
  Telephone: - -   Ext.
  Street address:
  City:
  State:
  ZIP or postal code:
Pharmacy (2) Information Return to Top  
  Please enter information about any employer sponsored health plans or personal health plans for which the patient is the primary beneficiary.
  Pharmacy:
  Telephone: - -   Ext.
  Street address:
  City:
  State:
  ZIP or postal code:

Medical Information Return to Top  
 
Conditions and Illnesses
  Please check any conditions or illnesses you have experienced.
Allergies
Arthritis or rheumatism
Asthma
Back trouble
Bladder problems
Blood anemia or disease
Blood clotting problems
Bone or joint problems
Bones broken
Cancer, cyst, growth, tumor
Chest pain or pressure(angina)
Cholesterol problems
Cough or bronchitis
Depression, worry, anxiety
Diabetes
Digestive problems (constipation, diarrhea)
Dizziness or fainting spells
Drug reaction or sensitivity
Epilepsy (fits or convulsions)
Eye trouble or injury
Fatigue (tired all the time)
Gall bladder trouble
Headaches, frequent or severe
Heart disease
Heart murmur
Heart palpitations or fluttering
Hepatitis (liver disease)
Hernia
High blood pressure (hypertension)
Irritable Bowel Syndrome
Kidney trouble
Lung trouble
Neck problems
Prostate problems
Rectal disease or bleeding
Sexually transmitted disease
Shortness of breath
Sinus trouble
Skin disease or trouble
Sleep difficulties
Stomach problems
Thyroid or goiter trouble
Ulcers
Urination, painful or frequent
Weight loss or gain (past year)
Other
     
  This space is for any details related to any conditions you've checked.  
   
Exams, Tests and Characteristics Return to Top  
  Enter information regarding any of your tests results, measurements or important health characteristics.
   
  Have you ever been given a complete physical?  
      If so, do you know the date of the most recent exam and the results?
date:            		 
  Have you had an dental exam?  
      If so, do you know the date of the most recent exam?
  
  Have you had an eye exam?  
      If so, do you know the date of the most recent exam?
  
  Do you have any physicial limitations? Please describe.
  
       
  Have you ever had an EKG (electrocardiogram), exercise stress test, or echocardiogram?  
      If so, do you know the date of the most recent exam and whether the results normal or abnormal?
date:            normal abnormal
 
  Have you ever had your blood pressure measured?  
      If so, do you know the date of the most recent measurement and the reading?
date:            systolic diastolic 		 
  Have you ever had your blood sugar (glucose) measured?  
      If so, do you know the date of the most recent measurement and the results?
date:            ???????? 		 
  Have you ever had you blood lipids (cholesterol) measured?  
      If so, do you know the date of the most recent measurement and the results?  
      date:
 
      Total cholesterol:  
      LDL:  
      HDL:  
      Triglycerides:  
         
  [Women] Have you ever had a Pap smear?  
      If so, do you know the date of the most recent exam and whether the results normal or abnormal?
date:            normal abnormal 		 
  [Women] Have you ever had a mammogram?  
      If so, do you know the date of the most recent and whether the results normal or abnormal?
date:            normal abnormal 		 
  [Men] Have you ever had a prostate exam? If so, do you know the date of the most recent exam?  
      date:  
  [Men] Have you ever had a testicular exam? If so, do you know the date of the most recent exam?  
      date:  
         
Lifestyle and Social History: Part 1 Return to Top  
  Please answer...
    Would you rate your present health?  
   
excellent   good   fair   poor  
 

Do you participate in exercise regularly apart from normal work activities? 

 
    If so, what type?
 
  Are you currently taking any prescription, over-the-counter or herbal medications?   
      If so,
regularly occasionally
 
      If so, which ones?
 
  Have you consulted any physician, practitioner, hospital, or clinic during the past 5 years?  
       Explain:
  
  Have you ever undergone surgery?  
   

 

  If so, what type and when?
 
  Do you use, or have you ever used alternative therapies (acupuncture, biofeedback, homeopathy, hers, etc.)?  
   

 

 If so, please provide details about when and what.
  
  Are you currently employed?
 		 
      Job Title:
Average hours per week: 		 
    On a scale from 1 to 10 (10 =excellent), how would you rate your overall work-related satisfaction?   
     
    On a scale from 1 to 10 (10 =excellent), how would you rate your overall home/family satisfaction?   
     
    On a scale from 1 to 10 (10 =high), how would you rate your overall stress level?   
     
Lifestyle and Social History: Part 2 Return to Top  
  Please answer...
  Is there a friend or family member you can easily talk to about personal matters?  
  Have you been or are you now under the care of a doctor for mental, emotional or psychiatric illness?  
  Do you use a birth control method?  
      If so, please specify:

 
  Do you have any children?  
      If so, how many?
  
  [Women] Have you ever been pregnant?  
      If so, how many times?
  
  [Women] When was the first date of your last period?  
      date:  
  [Women] Do you have any menstrual or reproductive problems?  
      If so, please specify:
 
  Would you like some information about safe sex?  
  Have you experienced frequent sexual difficulties?  
  Do you believe that you may have been exposed to the AIDS virus?  
 

Do you use tobacco?

 
   

 

 If so, which types?
cigarettes   cigars   pipe   chew   snuff		  
      If so, how much?
      
For how many years?
 
      If so, when did you or do you plan to quit?
 
  Do you drink alcohol?  
      If so, please estimate weekly amount.