Past Medical History Form Patient Name Female
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- Emory Lee
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1 Past Medical History Form Patient Name Female How did you hear about us? M- Mother F- Father MGM- maternal grand mother MGF- maternal grandfather PGM-paternal grandmother PGF- paternal grandfather MA- maternal aunt PA- paternal aunt MU-maternal uncle PU- paternal uncle B- Brother SIS- Sister SON-son DA- daughter Have you ever had or have: Personal History Family History X Disease Date of Diagnosis/ Explanation Which family member- use key High blood pressure High cholesterol Abnormal heart rhythm Heart murmur Peripheral arterial disease Congestive heart failure Heart attack Other problem with heart or arteries/veins Asthma Allergies Blood clot in lung Pulmonary high blood pressure Sleep apnea (stop breathing when asleep) Excessive snoring Chronic sinus issues COPD Emphysema Other lung problems Stomach ulcer Chronic heartburn Irritable bowel syndrome Crohn s disease Ulcerative colitis Chronic constipation Hemorrhoids Pancreatitis Liver disease/ Hepatitis Gallstones Diverticulitis Other problems with your digestive tract Hypothyroidism Hyperthyroidism Diabetes Osteopenia/ Osteoporosis Other endocrine issues
2 Disease Date of diagnosis/ Explanation Which Family Member X Warts Eczema Psoriasis Abnormal moles Seizures Migraines Chronic headaches Stroke or TIA Dementia Other neurological problems Urinary leakage Endometriosis Fertility Problems Uterine Fibroids Poly cystic ovarian disease Sexually transmitted disease Irregular periods Kidney stones Gout Arthritis Rheumatoid arthritis Fractures Lupus Blood transfusion Clotting/ Bleeding issues Anemia Sickle cell trait/ Disease Thalassemia Anxiety Bipolar Disorder Depression ADD/ADHD Substance abuse/inc. alcohol Cancer Other medical issues not listed What kind What type/ treatment
3 Surgeries X Surgery Date X Surgery Date Tonsillectomy Hysterectomy Tubes in ears Tubal ligation Appendectomy Cataract R/L Gallbladder removal Cosmetic Back Surgery Heart Surgery Joint Surgery Hernia Joint replacement C-section Other Other Procedures Have you ever had: X Procedure Date X Procedure Date Heart catheterization Mammogram Colonoscopy Upper scope (EGD) Bone Density Scan Prostate Check or PSA Echocardiogram Gyn How old were you with your first period? Are you (or have you ever been) sexually active? Y N Age of Menopause Do you have sex with men, women or both? What type of birth control do you use? How many Total pregnancies have you had? Total # (including miscar/abortions) Deliveries # Miscar # Abortions # Last Pap Smear: Abnormal Pap? (date and treatment) Do you perform self breast exams regularly? Y N Have you had a mammogram? Y N Last date: Any abnormal mammo? Have you had a bone density scan? Y N Date and result: Have you had Gardasil vaccines? Y N Dates: Date of last tetanus booster?
4 Social Occupation: Highest level of education: Marital Status: Single Partner(girlfriend/boyfriend) Engaged Married Divorced Widowed Number of children: Biological: Stepchildren: Adopted: Do you live by yourself or with others? Exercise level? None 1-2/week 3-4/week 5-7/week How many alcoholic drinks per week? Never Rare >14 Y Have you ever had a problem with alcohol use? Diet Regular Vegetarian Vegan Gluten-free Other N General Stress Level Low Medium High Have you ever smoked? Current? How much? How long? Past? How much? How long? Smokeless tobacco? Cur/Past? How much/ How long? Regular use of marijuana? Other illicit drugs? Past/Present? Any problems with drug use? Y N Any problems with controlled substances? Like prescription medications? Do you drink caffeine? How much per day? Soda? (Diet) # (Sugar)# Coffee # Tea# Energy Drinks# Safety Do you use seatbelts regularly? Do you use sunscreen regularly? Do you have guns present in the home? Do you have a smoke alarm at home? Do you wear a bike helmet? Any history of domestic violence? Any history of sexual violence? If so are they locked away from children? Personal Do you have any pets? What do you like to do for fun or pass time? Other things that you would like to share about yourself?
5 Medication Allergies/Food Allergies/Contact Allergies Medication/Food/Contact Reaction Current Medications Please list reason for taking each medication Vitamins/ Supplements Past Medications Medication Reason for taking Medication Reason for taking Health Goals Please list health goals that you would like to reach for yourself
6 Female Review of Systems Please circle recent symptoms and use lines below to explain. List #. 1. Constitutional: fatigue, poorly (malaise), fever, night sweats, weight gain or loss that doesn t make sense 2. Eyes: dry eyes, irritation, vision change, discharge from eyes, foreign body sensation in eyes 3. Ears: ear pain, ear congestion, ears popping, discharge from the ears, difficulty hearing 4. Nose: nasal congestion, nasal discharge, post-nasal drip, maxillary sinus pain, frontal sinus pain 5. Mouth/Throat: sore throat, snoring, mouth ulcer, teeth abnormalities 6. Cardiovascular: chest pain, shortness of breath when lying down, rapid or irregular heartbeat (palpitations), excessive sweating 7. Respiratory: cough, wheezing, shortness of breath 8. Gastrointestinal: heartburn, nausea, vomiting, diarrhea, constipation, abdominal pain, bloating 9. Genitourinary: pain with urination, urine leakage, foul-smelling urine, increased urinary frequency, blood in urine, abnormal vaginal discharge, abnormal periods 10. Musculoskeletal: muscle aches, muscle weakness, joint pain, back pain 11. Skin: abnormal moles, rash, abnormal skin lesions, breast lump, change in the breast skin 12. Neurologic: headaches, dizziness, weakness, numbness 13. Psych depression, anxiety, sleep disturbances, mania, feeling unsafe in relationship, alcohol or substance abuse, difficulty falling asleep, early morning waking, not feeling rested after adequate sleep, loss of interest in activities, loss of pleasure from usual activities, inappropriate feelings of guilt, decreased energy, decreased motivation, decreased concentrating ability, abnormal appetite, feeling like hurting self, feeling so badly that you wouldn t mind if you died in your sleep, feeling actively suicidal, feeling emotionally detached, feeling unique and all-powerful (grandeur), disturbing or unusual thoughts, feelings, or sensations, decreased need for sleep, impulsive behavior, pressured speech, causing anger in friends and family 14. Endocrine: change in weight distribution, increased hair loss, excessively dry skin, change in color of skin, feelings of weakness and fatigue, feeling more hot or cold than others, hot flashes, abnormal hair growth, 15. Hematologic/Lymphatic swollen glands, abnormal bruising 16. Allergies: runny nose, sinus pressure, itching, hives, frequent sneezing
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Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
Michigan State University Adult New Patient Forms
Your name: Preferred name, if other than given name: Date of birth: Phone number: Michigan State University Adult New Patient Forms Welcome to Michigan State University HealthTeam. Please take a few minutes
Pure Health Natural Medicine
Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell