Patient History Form

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1 Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name: Are we authorized to discuss medical information with your spouse? Anyone else? If so, whom Do you have any children? Child's name(s): Do we have permission to leave test results on your home answering machine if you are not available? List All Medication Allergies and Reactions List all Current Medications You Are Taking ITEM # Page 1 of 8

2 . Have you received any health care elsewhere in the last year? If yes, please list, including physicians, urgent care, therapists, chiropractors, outpatient tests. Date Provider or Site Reason PERSONAL HABITS Do you have a living will? Do you have Power of Attorney? Do you wear seat belts? Do you exercise regularly? Type Do you chew tobacco? Do you drink alcohol? Check the type of alcohol consumed Do you now or have you ever smoked? If you have quit, how long ago? Are you exposed to secondhand smoke? Do you use illicit drugs? Do you feel you have a dependency on any prescription drugs? (if yes, please provide copy) (if yes, please provide copy) times per week packs per week for years beer wine liquor packs per week for years PAST MEDICAL HISTORY 1. Indicate any operations that you have had. Give date if known. 2. Indicate any hospitalizations for non-surgical illnesses. Give date if known. ITEM # Page 2 of 8

3 3. Have you ever had any of the following? Check all that apply. alcohol/drug dependency asthma or hay fever blood transfusion cardiac arrhythmia depression gallbladder disease heart disease high blood pressure HIV skin disease ulcers Other: anemia back trouble bone disorder colitis diabetes heart attack hemorrhoids jaundice osteoporosis stroke / TIA varicose veins anxiety / panic disorder bleeding disorder breast problems colon polyps diverticulitis heart failure hepatitis / liver disease kidney stones pneumonia thyroid disease arthritis blood clots or phlebitis cancer convulsions/ seizure emphysema heart murmur hernia migraines sexually transmitted disease tuberculosis 4. Indicate any major childhood illnesses: 5. When was your last physician exam? Include date and provider. If you have had any of the following, please indicate date: Date Flu shot Chest x-ray Hepatitis B vaccine Dental exam Pneumonia vaccine EKG TB skin test / PPD Eye exam Tetanus vaccine Mammogram (last) Cholesterol screen Stress test Colonoscopy Date ITEM # Page 3 of 8

4 For WOMEN only: Date of your last menstrual period: Are you menopausal? If yes, date of onset: Have you taken estrogen replacement? If yes, how long have you been on replacement therapy? When did you begin this therapy? Number of pregnancies: Number of live births: Number of miscarriages or abortions: Date of last Mammogram / never Have you been instructed in proper self breast exam technique? Do you perform self-breast exams? For MEN only: Do you practice regular self-exams? FAMILY HISTORY UPDATE If living If deceased FATHER MOTHER GRANDFATHER (FATHER SIDE) GRANDMOTHER (FATHER SIDE) GRANDFATHER (MOTHER SIDE) GRANDMOTHER (MOTHER SIDE) BROTHER OR SISTER Age Health Age Cause of Death ITEM # Page 4 of 8

5 Has any blood relative developed any of the following in the past year? Please Check: Alcohol Abuse Alzheimer's Disease Aneurysm Cancer / Breast / Kidney / Ovarian / Prostate / Other Colon Polyps Diabetes Epilepsy Heart Disease High Blood Pressure Kidney Disease Melanoma Stroke Who: Listed below are specific symptoms or conditions you may have had trouble with in the past year, or you may be having trouble with now. They are grouped into body systems such as skin, eye, abdominal organs, etc. Please read each system in its entirety before answering. If you have had no problems with any of the symptoms listed under a given heading, check NO next to the system title. If you are having problems, then check the YES next to the specific symptom. GENERAL HEALTH NOSE AND SINUSES fever night sweats frequent nose bleeds hay fever hot flashes significant weight gain sinus congestion MOUTH AND THROAT ITEM # Page 5 of 8

6 significant weight loss sores in mouth loss of appetite ENDOCRINE GLANDS goiter (enlarged thyroid) problems with tonsils hoarseness LUNGS overactive thyroid cough underactive thyroid coughing up blood excessive thirst shortness of breath excessive hunger SKIN get winded easily emphysema rash chronic bronchitis sores wheezing boils eczema moles (that have changed color or size) LYMPH GLANDS positive tuberculin skin test HEART AND BLOOD VESSELS chest pain chest discomfort swelling in the neck wake up short of breath swelling in the armpit rapid heartbeat swelling in the groin EARS difficulty hearing irregular heart beat heart murmur rheumatic fever drainage from ears palpitation (heart thumps) frequent ear infections swelling in ankles pain in ears vein problems in leg EYES wear gasses or contacts eye pain.. cramps in legs when walking ABDOMINAL ORGANS abdominal pain glaucoma bloating after meals sudden changes in vision heartburn / indigestion double vision ulcers blurred vision vomiting blood blind spots liver disease ITEM # Page 6 of 8

7 KIDNEYS OR BLADDER difficult / painful urination blood in urine cannot hold urine. jaundice hepatitis gallstones frequent use of antacids very frequent urination heavy drinking get up more than once at night to urinate frequent infections difficulty swallowing constipation kidney disease kidney stones protein in urine sugar in urine MUSCLES, BONES, JOINTS deformities muscle weakness. recent change in bowel habits blood or mucus in stool black, tarry stool hemorrhoids rectal pain GENITALS - WOMEN date of last menstrual period pain in joints date of last Pap smear chronic pain in back birth control method swelling in joints gout do you know how to examine your breasts? This past year have you had: NERVOUS SYSTEM frequent/ severe headaches abnormal Pap smear unusual vaginal discharge. head injury seizures/ fits/ convulsions irregular period abnormal bleeding epilepsy numbness or tingling pain with intercourse pelvic pain weakness breast lumps difficulty sleeping suicidal thoughts nipple discharge venereal disease ITEM # Page 7 of 8

8 severe anxiety GENITALS - MALE sores on penis discharge from penis prostate gland trouble difficulty urinating impotence venereal disease Do you do self testicular exams? Patient Signature Date Time AM / PM ITEM # Page 8 of 8

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