History & Review of Systems Screening. Medical History

Transcription

1 History & Review of Systems Screening Patient name: Date: / / Pharmacy name:_ Primary Care Physician: Referring Physician: Height: Weight: R or L handed Medical History Please tell the doctor if you have been treated or currently have any of the following. Circle all that apply. High Blood Pressure Stroke Heart Disease Ulcers Cancer Alcoholism Diabetes Gout Depression Asthma Hepatitis A B C Anxiety Disorder Emphysema Seizures Mental illness Chronic Bronchitis Migraine HIV/ Aids Prostate problems Fibromyalgia Osteoporosis/Osteopenia Kidney/ Urinary disease Thyroid disease Reaction to anesthesia Drug or Alcohol addiction Tuberculosis Malignant Hyperthermia Blood disorder (sickle cell, hemophilia, etc.) High Cholesterol Rheumatoid arthritis Other diseases or disorders: Surgical History Please list all surgeries including approximate date Printed name Date of Birth Signature 1

2 Social History Marital Status: Married Single Widow Significant Other Occupation: Do you smoke NO YES How many packs per day? If you quit smoking, when did you quit? Do you drink alcohol? NO YES How often? Rarely Occasionally Socially Daily If you don t drink now, did you in the past? NO YES How much? Do you use recreational drugs? NO YES If yes, what type? Family History Circle all that apply Mom: living or deceased Cancer Diabetes Heart disease high blood pressure Dad: living or deceased Cancer Diabetes Heart disease high blood pressure Maternal Grandfather: Cancer Diabetes Heart disease high blood pressure Maternal Grandmother: Cancer Diabetes Heart disease high blood pressure Paternal Grandfather: Cancer Diabetes Heart disease high blood pressure Paternal Grandmother: Cancer Diabetes Heart disease high blood pressure Other relevant family history: CURRENT SYMPTOMS Please circle all that apply. Fever Chest Pain Fainting/ Seizures Shortness of Breath Nausea/vomiting Bleeding tendencies Fatigue Anemia Painful urination Printed name Date of Birth Signature 2

3 Blurred Vision Rashes Other: MEDICATIONS Please list all medications, including supplements; you are currently taking along with the dosage and frequency. Please use back of the page if you do not have enough room. MEDICATION Dosage Frequency Example: Tylenol 500mg 3 x a day ALLERGIES Please list drug allergies you have along with the reaction. Example: Sulfa/itching: Medication Reaction Printed name Date of Birth Signature 3

4 ACCIDENT/INJURY DETAILS Patient name: Date / / What body part are we seeing you for today? Indicate side of the body? RIGHT LEFT BILATERAL (both) Date of injury/ onset of problem: / / Injury details: If not an injury, how long have you had this problem? _ Have you had surgery to this body part before? YES NO Please describe your pain (Example: achy, throbbing, stiff, sore, weak) What makes it worse? What makes it better? Are you taking medication for this problem? Have you had Physical Therapy for this problem? YES NO Have you had an injection for this problem? YES NO Date: / / Please rate your pain and circle the number that applies to you 0= no pain 10= severe Printed name Date of Birth Signature 4

5 ACCIDENT/INJURY DETAILS CONTINUED Was this a result of a motor vehicle accident? YES NO Did the accident involve another party? YES NO Did this injury happen on a job? YES NO Did or will you be filing a worker s compensation claim for this injury? YES NO At this time, is it anticipated that another party (other than your own health YES NO Insurance/ worker s compensation) be responsible for medical expenses related to this injury? If yes please provide name, address, and phone number of responsible party. Printed name Date of Birth Signature 5

6 Printed name Date of Birth Signature 6