MEDICAL HISTORY (To be filled in by patient)

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1 MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician)

2 I. Have you had any reactions, allergies or bad effects from any of the following: Serum Penicillin Other Antibiotics Codeine Sulfa Drugs Yes No Yes No Aspirin Morphine Other drugs (specify) II. Have you ever had any of the following: (If Yes, please check) 1. Measles 13. Cancer or Tumor 2. Mumps 14. Fits or Epilepsy 3. Chicken Pox 15. Heart Attack 4. Whooping Cough 16. Other Heart Disease 5. Scarlet Fever 17. Tuberculosis, Asthma or Emphysema 6. Diphtheria 18. Ulcer or Colon Problems 7. Rheumatic Fever 19. Gallbladder Disease 8. Glaucoma 20. Kidney or Bladder problems 9. Migraine Headaches 21. Arthritis or Gout 10. Stroke or Paralysis 22. Anemia Have you had illnesses other than those listed above? Yes No (If Yes, please list) III. Do you take any of the following medications or drugs regularly? (If Yes, please specify dose & interval) Digitalis (Medicine for the heart) Anticoagulants Diuretics Tranquilizers Insulin Aspirin Thyroid Sleeping Pills Drugs to lower high blood pressure Nitroglycerine Any Others (please list)

3 Relation Age If Living If Deceased-Cause Of Death Age At Death Father Mother Brothers Sisters Grandparents, Aunts Or Uncles Children Male Children Female IV. List any significant family illnesses other than listed above: V. Operation: Have you had any surgical treatment or operations? (If Yes, list below) _ VI. VII. Have you had any serious accidents or injuries? (If Yes, list below) Menstrual History: 1. Number of pregnancies? 2. Number of living children? 3. Did you have any miscarriages? 4. If Yes, how many? 5. Have your menstrual periods stopped? When 6. Did you have any difficult deliveries? 7. Did you have heart or kidney trouble during pregnancy?

4 VIII. Habits: Do you now or have you ever smoked? Yes No Cigars Cigarettes Pipe Other (Please Circle what applies) If yes, how much? How long If you have stopped, how long ago Do you follow a regular exercise program? Do you drink alcoholic beverages? Never Occasionally Almost Daily More than above (Please Circle what applies) Do you drink coffee, tea or other caffeinated beverages? Yes No (Circle One) If yes: Less than 5 cups per day More than 5 cups per day Are you on any special diet? (Please specify) IX. Risk Factors: Yes No Don t Know 1. Has anyone in your immediate family had a heart attack, angina, heart surgery, died suddenly, or had angioplasty/stents? 2. Do you have high cholesterol? (Greater than 240 mgm/dl) 3. Do you have high blood pressure? 4. Do you have sugar diabetes? 5. Do you have gout or a high uric acid? 6. Are you significantly overweight? (Greater than 20% above ideal bodyweight) 8. Are you sedentary? (Exercise less than 3 times per week for at least 20 minutes) 9. Do you plan on starting an exercise program? 10. Have you ever had discomfort in the chest, neck, shoulders, arms, jaw or throat during exercise or stress? 11. Do you get short of breath easily during everyday activities? 12. Do you get cramps in your calves or thighs when walking or climbing stairs? 13. Have you ever had a temporary loss of vision in one eye? 14. Are you post-menopausal?

5 X. Have you ever had or do you now have any of the following? (If Yes, please check) Headaches Dizziness or Blackouts Goiter or Thyroid trouble Hearing or Ear condition Hay fever Eye or Vision problems Frequent sore throats Pain or difficulty swallowing Frequent hoarseness Chronic cough Coughed up blood Severe or recurrent pain in chest Pneumonia or Pleurisy Heart murmur Shortness of breath climbing stairs Swelling of ankles Irregular palpitations or Fast heart beat Pain or Cramps in legs with walking Varicose veins or Phlebitis Recent change in appetite Change in weight Vomiting of blood Frequent vomiting Recurrent burning in stomach Frequent diarrhea or constipation Yellow jaundice Pain after drinking alcoholic beverages Chronic abdominal pain Frequent belching or bloating Hemorrhoids Rupture or Hernia Red blood or Black tarry stools Excessive thirst Trouble starting or stopping urine Frequent or painful urination Skin cancer Shingles more than once Alcoholism Narcotic or drug habit Car, air or sea sickness Tremor or Palsy Difficulty sleeping Frequent or terrifying nightmares Attempted suicide Frequent depression Urinate more than once a night Dribbling of urine Prostate problems Disabling back pain Bone, joint or other deformity Neuritis Blood disorder Chronic skin condition Hives Ulcer of legs or feet

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