Name:
Kaiser Foundation Health Plan of the Northwest  Kaiser Foundation Hospitals

HR #: DOB: Clinician:

Personal Health Profile
Medications (Prescription and over-the-counter drugs) Drug Names Strength Frequency

Medical Office: Occupation: Medication Allergies Drug

Reaction

Major Surgeries or Injuries (Include year if known)

Other Hospitalizations (Include year)

Have you been treated for any of the following? Yes No Yes No Yes   Diabetes   High Cholesterol    High Blood Pressure   Heart Disease    Thyroid Disease   Lung Disease   Other (Explain) Does your mother, father, sister or brother have any of the following? Yes No Yes No Yes   Diabetes   High Cholesterol  Alcohol/Drug Abuse Have you been sexually active in the past 6 months? No  Do you use birth control? No  Yes  Method: When was your last tetanus shot?   High Blood Pressure  

No  

Cancer Mental/Emotional Problems

Heart attack before age 55   Breast, Colon or Prostate Cancer Yes  If yes, how many partners? No  Yes 

No 

If over 65, have you had a pneumovax vaccine?

Have you ever smoked? No  Yes  Do you smoke or use smokeless tobacco? No  Yes  Do you use alcoholic beverages? No  Yes  If yes, how many drinks on an average per week (1 drink=1glass beer/wine or 1 shot hard liquor)  1 to 5  6 to 10  11 to 20  More than 20 Do you exercise regularly? If yes, what type? No  Yes  Do you use recreational or “street drugs”? No  Yes 

12803 6/09 HAP Administration/MPO

PERSONAL HEALTH PROFILE

Name:
Kaiser Foundation Health Plan of the Northwest  Kaiser Foundation Hospitals

HR #:

Personal Health Profile
WOMEN ONLY: Have you gone through menopause? No  Yes  If yes, when? If not, when was the first day of your last period? Date of last pap smear Date of last mammogram Review of Systems: WT: HT: Vision: Uncorrected