Medical History Form
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- Malcolm Harris
- 5 years ago
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1 General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which: Conventional Oriental : Please list the names of the physicians you have formerly consulted with for this problem: 3. Hospitalizations and Surgeries: Have you undergone any hospitalizations or surgeries in the past? Yes No, if yes, please explain: 4. Medications and Supplements: What medications and supplements are you currently taking? a. Prescription: b. Non-prescription: c. Supplements: d: Herbs: 5. Allergies: Are you allergic to any medications, foods, or environmental products? Yes No, if yes, please explain: 6. Mental Disorders: Have you ever been diagnosed with a mental disorder? Yes No, if yes, please explain:
2 7. Communicable Diseases: Do you have an active contagious diseases? Yes No, if yes, please check: Tuberculosis Pertussis Measles SARS Diphtheria West Nile Virus Meningitis Encephalitis Influenza Hepatitis A, B, C HIV/AIDS Tropical Diseases : 8. Family History: Please check if applicable Diseases Father Mother Brother Sister Cancer Diabetes Heart Diseases Stroke Mental Illness Please explain: System By System: Please check the boxes if applicable 1. Cardiovascular Heart Diseases Heart Murmurs Chest Pain Palpitations Arrhythmia Fainting Rheumatic Fever High Blood Pressure Stroke Swelling of Ankles Varicose Veins Deep Vein Thrombosis Easy Bleeding Easy Bruising Anemia Raynaud's Syndrome 2. Pulmonary Asthma Pleurisy Emphysema Cough Difficult Breathing Shortness of Breath Chronic Bronchitis Frequent Catching Colds Sleep Apnea Cardiac Asthma 3. Genitourinary Kidney Diseases Difficult Urination Frequent Urination Painful Urination Incontinence Urination at Night Kidney Stones Urinary Tract Infection
3 Blood in Urine Venereal Diseases 4. Neurological Dizziness Loss of Balance Muscle weakness Paralysis Numbness Tingling Seizures Epilepsy Memory Loss Insomnia Somnolence 5. Gastrointestinal Epigastric Pain Heartburn Nausea/Vomitting Ulcers Belching Bloating Gall Bladder Diseases Liver Diseases Abdominal Pain Hemorrhoid Blood in Stool Undigested Food in Stool Loose Stool Constipation Frequent Passing Gas 6. Endocrine Hypothyroid Excessive Thirst Hyperthyroid Excessive Hunger Hypoglycemia Night sweating Diabetes Feeling of Hot or Cold 7. Head Headaches Teeth Grinding Migraine TMJ/Jaw Problems Head Injury Trigeminal Neuralgia Cluster headache 8. Neck Lumps Neck Pain Goiter Whiplash Swollen Glands
4 9. Eye, Ear, Nose, Mouth, Throat Impaired Vision Sinus Problems Night Blindness Hay Fever Double Vision Stuffy Nose Blurred Vision Loss of Smell Spots in Eyes Nose Bleed Eye Pain Impaired Hearing Glaucoma Ear Ringing Cataracts Painful Ear Excessive Tearing Dry Throat Dry Eyes Sore Throat Chapped Lips 10. Integumentary, Musculoskeletal Rashes Shoulder Pain Acne, Boils Arm Pain Skin Color Changes Upper Back Pain Lumps Middle Back Pain Eczema Lower Back Pain Hives Leg Pain Psoriasis Arthritis Itching Joint Pain Hair Loss Muscle Spasms Brittle Nails 11. Immune Chronic Fatigue Low-grade Fever Chronic Infections Slow Wound Healing 12. Reproductive System Male Female Hernia Age of first mense? Sexual difficulties Age of menopause? Premature ejaculation Length of cycle? Penile discharge Duration of menses? Genital warts Irregular cycles Chlamydia PMS Gonorrhea Heavy flow Syphilis Clotting Herpes Menopausal symptoms
5 Prostate problem Vaginal discharge Testicular pain Date of last PAP exam? Testicular swelling Endometriosis Ovarian cysts Breast lumps Nipple discharge Pain with intercourse Vaginal dryness Cervical dysplasia Genital warts Chlamydia Gonorrhea Herpes Syphilis Birth control? Number of pregnancy? Number of live birth? Number of miscarriages? Number of abortions? Difficulty conceiving 13. Mental/Emotional Mood swings Neurosis Depression ADHD Nervousness Hallucinations Bi-polar Suicidal thoughts Psychosis Mental tension Anxiety
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Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees