Northern Monmouth County Medical Associates
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- Brittany Cox
- 5 years ago
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1 Northern Monmouth County Medical Associates 195 Route 9; Suite 112 Manalapan, NJ (732) FAX: (732) DATE: COMPLETE MEDICAL HISTORY FORM NAME: AGE: DATE OF BIRTH: I. CHIEF COMPLAINT: Main reason for your visit today? Please list anything you would like to discuss with the doctor: II. PAST MEDICAL HISTORY A. Surgeries: Past Surgeries? (Yes/No): If yes, type of surgery: Date of Surgery: B. Hospitalizations: (other than for surgeries) Date: Where: Reason? C. Injuries/Fractures (type, date and how injured): D. Present Medications (prescription and over-the-counter): Name Dose # Taken Daily Reason Herbs and Supplements: E. Allergies: Yes or NO (circle one) Medications: What type of Reaction: Other Substances, Foods, etc: F. Immunizations: Check Childhood Shots Given (and provide dates, if known): DPT Mumps Measles Rubella Polio Smallpox
2 III. FAMILY HISTORY Mother: Age (if living) Age (at death) Cause of death List any medical problems she has had: Father: Age (if living) Age (at death) Cause of death List any medical problems she has had: Brother(s): Ages and any medical problems he/they have had: Sister(s): Ages and any medical problems she/they have had: IV. LIFESTYLE HISTORY A. Marital Status: Single Married Divorced Significant Other (male) Significant other (female) B. Have you ever been pregnant? Yes No N/A If yes, how many pregnancies? How many births/children? C. Smoker? currently ex-smoker nonsmoker chewing tobacco If a smoker, number of packs (pipes, cigars) per day: How long have you smoked? If ex-smoker, when did you quit? D. Alcohol intake: What do you usually drink? how much? how often? Do not drink alcohol E. Exercise: Do you exercise regularly? What activity? How often? How long is each session? F. Diet: Check any foods you avoid in your diet: salt sugar fats (oils) red meat eggs poultry wheat caffeine other G. Usual # of meals per day: # of times per week you eat fast foods H. Travel: Have you recently traveled outside the U.S.?
3 Where did you go? I. Work: Occupation: Work related illnesses or injuries? Injury/Illness while employed as: Do you have a history of exposure to toxic chemicals or substances? Yes No What Where When V. HEALTH MAINTENANCE A. Date of last physical/annual exam Examiner B. Date of last Pap smear C. Date of last Prostate exam D. Date of last Sigmoidoscopy or Colonoscopy E. Date of last Bone Density F. Date of last mammogram VI. REVIEW OF SYSTEMS A. In the past, have you been diagnosed as having any of the following conditions? Check and date: High Blood Pressure Varicose Veins Hardening of the Arteries Phlebitis (blood clots) Heart Attack Headaches (migraine, cluster, or tension) Stroke or TIA High Cholesterol or Triglycerides Heart Murmur Sexual Dysfunction Angina Congestive Heart Failure Cataracts Glaucoma Sinusitis Menieres Disease Nasal Polyps Allergic Rhinitis Tonsillitis Gum Disease Cervical (neck) Strain Arthritis Lupus Rheumatoid Arthritis
4 Emphysema Pneumonia Fibrocystic Breast Disease Hyperthyroidism (over-active thyroid) Pernicious Anemia Peptic Ulcer (gastric or duodenal) Gastritis / Esophagitis Intestinal Polyps Diverticulosis Irritable Bowel (spastic colon) Reflux or GERD Fibromyalgia Ulcerative Colitis Hemorrhoids Epididymitis Cancer (any kind) Vaginitis Pyelonephritis (kidney infection) Kidney Stone Hypoglycemia Bulimia or Anorexia Abnormal pap smear Abnormal x-ray finding Chronic Bronchitis Asthma Galactorrhea (breast discharge) Hypothyroidism (low thyroid) Lymphoma Iron Deficiency Anemia Diabetes Malabsorption Diverticulitis Chronic Fatigue Syndrome Enlarged Prostate Crohn s Colitis Prostatitis (prostate infection) Pelvic Inflammatory Disease Uterine Fibroids Cystitis (bladder infection) Hepatitis A, B, or C Panic Attacks Gallstones PMS or PMDD or Dysmenorrhea Depression Multiple Sclerosis Neurologic Disease B. Presently or in the recent past, have you had any of the following symptoms?: Recurrent Headaches Weight Loss # of pounds lost Fever (unexplained) Chills Generalized Fatigue Generalized Weakness Double Vision Ringing in ears Recurrent sinus infection Recurrent sore throats Hoarseness Neck Stiffness Coughing up blood Chronic Cough Chest Pressure/Tightness on exertion Chest Pressure/Tightness at rest Feeling dizzy or off-balance Pain in legs while walking Change in appetite Abdominal burning pain Nausea Diarrhea Change in bowel habits Rectal Bleeding
5 Painful urination Change in urinary habits Breast Pain Weight Gain # of pounds gained Night Sweats Generalized Body Aches Change in vision Change in hearing Frequent nosebleeds Recurrent gum or tooth infections Constant sinus drainage Trouble swallowing Swollen glands Shortness of breath on exertion Shortness of breath laying down Coughing up phlegm in morning Feeling faint or almost passing out Swollen ankles or feet Heartburn or indigestion Abdominal cramping pain Vomiting Constipation Blood in urine or stool Frequent or urgent urination Head injury and loss of consciousness Vaginal discharge or odor Change in menstrual periods Change in sexual desire Breast lump Nipple discharge Testicular pain Skin rash Easy bruising or bleeding Changes in hair Trouble sleeping Depression Muscle weakness or pain Tingling in hands or feet Joint swelling or joint pain Testicular swelling Changes in skin or moles Lumps in neck, underarms, or groin Sensation of being too hot or cold Nervousness, panic Mood swings Numbness Memory loss Seizures or convulsions
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Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
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