Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
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- Shanon Craig
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1 Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma Non-melanoma skin cancer (e.g. Basal cell carcinoma, squamous cell carcinoma or other) Tanning bed use Blistering sunburns Abnormal moles Eczema Psoriasis EYES, EARS, NOSE AN THROAT YES NO Yes - Details Glaucoma, cataracts, macular degeneration, or other eye disorder Cold sores (herpes infection) RESPIRATORY YES NO Yes - Details Asthma Lung disease (e.g. collapsed lung, interstitial lung disease, etc.) History of tuberculosis or positive PPD CARDIOVASCULAR YES NO Yes - Details Pacemaker / defibrillator Heart murmur Artificial heart valve High blood pressure High cholesterol ENDOCRINE YES NO Yes - Details Diabetes Thyroid disease GASTROINTESTINAL YES NO Yes - Details Inflammatory bowel disease (e.g. Ulcerative colitis or Crohn s) Hepatitis Liver disease Reflux (GERD) and/or stomach ulcers GENITORURINARY YES NO Yes - Details Kidney disease
2 Appointment Date: Page 2 MUSCULOSKELETAL YES NO Yes - Details Arthritis (please specify: osteoarthritis, rheumatoid arthritis, psoriatic arthritis, or other type) Artificial joint(s). If Yes, what year? ALLERGIC / IMMUNOLOGIC / INFECTIONS YES NO Yes - Details AIDS/ HIV infection Autoimmune disease (please specify if known) Prior Staph or MRSA infection Organ transplant recipient/immunosuppression Previous radiation therapy Previous or current chemotherapy History of ANY cancer HEMATOLOGIC YES NO Yes - Details Bleeding disorder (e.g. hemophilia, platelet disorder, etc.) Clotting disorder (e.g. blood clots, DVT, or pulmonary embolus, etc.) Lymphoma or leukemia NEUROLOGIC YES NO Yes - Details Demyelinating disease (e.g. multiple sclerosis, Guillain Barré syndrome, etc.) Migraines (if yes, do you have an "aura" such as sound or light preceding the migraine?) Parkinson s disease Seizures Stroke PSYCHIATRIC YES NO Yes - Details Anxiety disorder Depression Bipolar disease or other mood disorder OTHER MEDICAL DISEASE (Please specify) PAST SURGICAL HISTORY YES NO Yes - Details Abdominal surgery Cosmetic surgery Eye surgery Ear/nose/throat surgery Heart surgery Spine or brain surgery Any other surgery? (If yes, please provide details) FEMALES ONLY: Have you had a hysterectomy or tubal ligation? FAMILY SKIN HISTORY YES NO Are you adopted? Acne Which family members were affected? (Mother, Father, Grandmother, Grandfather, Brother, Sister, etc.)
3 Appointment Date: Page 3 YES NO Eczema Psoriasis Melanoma Non-melanoma skin cancer Abnormal moles SOCIAL HISTORY YES NO Do you use alcohol? If yes, How many times in the past year have you had 5 (for men) or 4 (for women and all adults older than 65 years) or more drinks in a day? unknown or more Smoking Status: Current every day smoker Current some day smoker Started Date: Ended Date: Have you had the flu shot within the last year? (If yes, select an option below) Former smoker Smoker, current status unknown Heavy tobacco smoker YES Influenza immunization previously received at home. Date: Influenza immunization previously received at work. Date: Date: If you re 65 or older; have you ever received a pneumonia vaccine? If Yes, date OCCUPATION What is your occupation? NO Never smoker Unknown if ever smoked Light tobacco smoker MEDICATIONS Are you currently taking any medications? Yes No **If yes, please complete section below. Medication name Dosage
4 Appointment Date: Page 4 Are you allergic to any medications? Yes Medication name No ** If yes, please complete section below. Reaction Review of Systems Are you currently experiencing any of the following symptoms? ALLERGIC/IMMUNOLOGIC YES NO Yes - Details Hives Swollen lymph nodes Tongue swelling CARDIOVASCULAR YES NO Yes - Details Chest pain Dizziness Irregular heart beat Leg swelling CONSTITUTIONAL YES NO Yes - Details Fever Chills Fatigue/ Malaise Night sweats Weight loss EARS, NOSE, THROAT YES NO Yes - Details Hearing difficulty Nose bleeds Sore throat Sinus trouble Stuffy nose ENDOCRINE YES NO Yes - Details Diabetes Heat / cold intolerance Loss of hair EYES YES NO Yes - Details Blurred vision Double vision Dry eyes Eye irritation
5 Appointment Date: Page 5 GASTROINTESTINAL YES NO Yes - Details Abdominal pain Change in appetite Constipation Diarrhea Heartburn/ reflux Nausea/ vomiting GENITOURINARY YES NO Yes - Details Blood in urine Frequent urination Foamy urine Painful urination GYNECOLOGIC (Females Only) YES NO Yes - Details Currently pregnant Currently nursing Trying to get pregnant Using hormone replacement therapy HEMATOLOGY/ LYMPH YES NO Yes - Details Easy bruising Easy bleeding Gums bleed easily MUSCULOSKELETAL YES NO Yes - Details Back pain Joint pain or swelling Muscle pain Stiffness NEUROLOGICAL YES NO Yes - Details Decreased strength Headaches Memory loss Numbness Paralysis PSYCHIATRIC YES NO Yes - Details Anxiety Depression Difficulty sleeping Homicidal thoughts Mood changes Suicidal thoughts RESPIRATORY Cough
6 Appointment Date: Page 6 Shortness of breath Wheezing SKIN Itching/ burning Itchy areas New or changing moles New rashes Other skin concerns Sores Thank you for completing your Past Medical History and Review of System forms. These will be included in your medical record.
Past Medical History. Chief Complaint: Appointment Date: Page 1
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