City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
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1 History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden name ) Ethnic Background: Caucasian African-American Asian Hispanic Native American Occupation: Current Duration months years Previous Hobbies/Leisure activities: _, _,, Toxic exposures with dates: (insecticides, solvents, chemicals, fumes,asbestos,irradiation ) Family pets:,, Foreign travel: Europe Dates Asia South America Africa
2 Tobacco use: Type Amount Duration Alcohol use: Type Amount Family Medical History : Father: living; age deceased; age Illnesses Mother: living; age deceased; age Illnesses Siblings: Brothers living ; ages, deceased; ages Sisters living; ages, deceased; ages Illnesses Children: Male; ages Female; ages Illnesses Diseases that run in the family: (circle all that apply) Lung Disease Skin Disease Tuberculosis Arthritis Heart Disease Diabetes Kidney Disease Hypertension Liver Disease Bleeding Disorders Personal Medical History: Stroke Blood Clots Anemia Leukemia Other Blood Disorders Cancer Gout Kidney Stones Birth Defects or Inherited Disorders Hospitalizations: Dates:,, Hospital,, Reason,, Surgery: Dates:,, Hospital,, Type,, Injuries: Dates:,, Type,, Medicine allergies: (Drug and type of reaction)_, Pregnancies: Full term, Miscarriages,
3 Personal Medical History (Continued): Current medications:(including vitamins and nonprescription drugs),,,,,,, Immunizations (with dates): Tetanus, Pneumovax, Influenza, Hepatitis A, Hepatitis B, Blood donations given, Dates:,, Blood transfusions received, Dates:,, Blood studies performed: Bone marrow aspiration, Dates Bone marrow biopsy, Dates Symptom Review ( Check and complete all that apply) Constitutional: Have you recently experienced? Fever Night sweats Weight loss, Amount Poor appetite, Weight gain, Amount Lack of energy Weakness Difficulty sleeping. Head Headaches; Type Duration Earache Right ear Left ear Loss of hearing, Right ear Left ear Ringing in the ear Right ear Left ear Dizziness or vertigo Loss of vision Right eye Left eye Double vision Treatment Spots or flashing lights Right eye Left eye Nose bleeds Sinusitis Gum bleeding Sore or burning tongue Mouth ulcers or sores Neck Chest Sore throat Swelling Hoarseness History of thyroid disease or goiter, Date, Treatment Heat or Cold intolerance, Pain Cough Asthma Sputum production Snoring or sleep apnea Bloody sputum Shortness of breath; At rest With exertion Lying down Last chest x-ray; Date TB skin test; Positive; Negative; Dates, Breasts: Pain Lumps, cysts Discharge Heart: Rheumatic Fever Heart murmur, _ Hypertension, Duration Irregular heart beat, History of heart attack, Date Chest pain with exertion, Duration Ankle swelling, Duration Pain in legs when walking,
4 Abdomen Inability to eat a full meal Change in abdominal size Difficulty swallowing Heart burn or Acid-indigestion Peptic ulcer Food intolerance, type Antacid use Hiatus hernia Specific food or ice craving Abdominal pain Location Genitourinary Tract Pain with urination Bleeding Urinary urgency Increased frequency Kidney stones Kidney infection, Dates Bladder infection, Dates Change in urine color Hepatitis Jaundice Liver disease Vomiting Vomiting blood Blood in the stool Black or tarry stools Change in bowel habits, _ Constipation Diarrhea Laxative use, type Getting up at night to urinate _ Bleeding between menstrual periods Excessive menstrual bleeding Vaginal infection Vaginal discharge Bones and Joints Joint pain Joint swelling Joint stiffness Numbness or tingling (pins and needles in hands or feet) Gout Pain in the arms, legs, hands or feet Burning pains in the hands or feet Muscles Muscle pain Muscle stiffness Nervous System Fainting episodes Seizures Stroke Temporary loss of vision Muscle cramps Memory loss Difficulty sleeping Depression Blood: Anemia, Dates:,,Treatment Result Abnormal blood counts, Type, Dates: Bleeding; Dates Treatment Phlebitis or blood clots; Site Dates, Swollen lymph nodes, location Skin: Rash Itching after a shower, bath or exercise Hair loss Hair gain Excema Psoriasis Change in skin color Change in skin texture
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