Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

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1 PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital Status: single married divorced widow/widower What hours do you work? Occupation: Ethnic Group: Black Caucasian Hispanic Other: Do you drink alcohol? YES NO If so, what type of alcohol? # of drinks per week or # of drinks per year Do you smoke? YES NO # of packs per day for years Are you a past smoker? YES NO Date stopped: Do you use any type of street or recreational drugs (cocaine, marijuana, etc.)? YES NO Do you exercise? YES NO If so, what type? How often? 1 GENERAL HEALTH STATUS Family History Father: living dead age of death (if applicable) cause of death Mother: living dead age of death (if applicable) cause of death Have you had a family member with any of the following? If so, check the correct box. Father Mother Children Brother / sister Grandparents Father Mother Children Brother / sister Grandparents Tuberculosis Heart disease Kidney disease Kidney stones High blood pressure Stroke Breast cancer Diabetes Thyroid disease Genetic disease Osteoporosis Bone fractures

2 High cholesterol Calcium problems 2 Please circle any health problems / procedures you currently have or have had in the past: Adrenal Gland Disorder Gallbladder removed Liver Disorder Appendix removed Glaucoma MRSA Cancer type Immune System Disorder Thyroid Disorder Cataracts High Blood Pressure Osteoporosis Congestive Heart Failure High Cholesterol Pancreatitis Diabetes Coronary Artery Disease Parathyroid Disorder Heart Attack Poor circulation in feet, legs Chronic Lung Disease (COPD) High Blood Pressure Mental Illness Pain Kidney Disease Hepatitis Blood Disorder Kidney Stones Pituitary Disorder Sleep Apnea CPAP Stroke Asthma Vasectomy Hysterectomy partial total Thyroidectomy (removal) total partial right left Have you had the pneumonia vaccine? YES NO If so, when? Do you take flu shots annually? YES NO

3 3 Please circle any symptoms that you are currently experiencing: General: weight gain weight loss fatigue insomnia fever lack of energy Name: Birth Date: HEENT: blurred/double vision lightheaded/dizziness eye pain eye swelling protruding eyes visual field changes seeing spots unusual dark circles around eyes nosebleeds sore throats difficulty swallowing voice changes mouth sores loss of taste abnormal taste bleeding gums frequent headaches Lymph: swollen glands lumps in neck Respiratory: shortness of breath wheezing snoring coughing unusual phlegm/mucus Cardiac: palpitations shortness of breath chest pain/pressure irregular blood pressure Endocrine: change in libido breast pain/tenderness breast discharge infertility hair loss Hair growth slow healing heat/cold intolerance hot flashes chills excessive sweating increased thirst unusual bruising rash itching easy bruising GI: nausea vomiting bloating abdominal pain heartburn diarrhea constipation blood in stool frequent bowel movements GU: blood in urine painful urination urinary incontinence increased urination unusual vaginal discharge irregular menstrual cycles painful menstrual cycles absence of menstrual cycles erectile dysfunction testicular pain/swelling Extremities: swelling muscle pains muscle cramps joint pain/stiffness Skin: change in nails dryness change in skin color skin sores unusual marks on skin Neurologic/Psych: seizures tremors/shakes anxiety depression irritability confusion difficulty with memory hyperactivity numbness tingling Women Only:/ Do you have children? YES NO If so, how many? Were you diagnosed with diabetes while pregnant? YES NO Any problems with the birth of your children? YES NO If yes, please explain: Do your children have medical problems? YES NO If yes, please explain: How old were you when menstrual periods first began? Are they regular? YES NO How many days do the periods last? How frequent? Date of last one: Date of last Pap smear: Results: Date of last mammogram: Results:

4 4 Do you have any reactions or allergies to medicine, food, latex, dyes or other? YES NO If so, please complete: Item Reaction Item Reaction 5 Please list ALL medications that you take: breakfast lunch supper Metformin 1000 mg 500 mg Name of Medicine Example Lantus Avandia 8 mg bedtime 14 units Name of Medicine breakfast lunch supper bedtime

5 PATIENT PROVIDER CARE LISTING Please list ALL physicians you are currently receiving care from: PREFERRED PHARMACY INFORMATION Local pharmacy information: Name: Address: Phone: ( ) Mail Order pharmacy Information: Name: Address: Phone: ( ) LABORATORY INFORMATION: Name: Phone: ( ) Please sign when completed: This questionnaire has been completed by: Relationship to the patient:

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