PATIENT MEDICAL HISTORY FORM Name: Date: Social Security #: DOB: Height: Weight: Email: Primary Care Physician: Referred by: Pharmacy Name/Location/Phone Number: Dialysis Center and Phone Number (if applicable): Do you have a: Pacemaker: Y N Defibrillator: Y N Cardiac Stents: Y N Name and Phone Number of Cardiologist: Chief Complaint: When did occur? Drug Allergies: Do You Take Blood Thinners? (circle) Coumadin Plavix Aspirin Xarelto Pradaxa What Medications are you currently taking? 1. 6. 2. 7. 3. 8. 4. 9. 5. 10.
List all of your current medical conditions (ex: high blood pressure, asthma, diabetes, etc.): 1. 4. 2. 5. 3. 6. Do you have hepatitis or any other chronic communicable disease?: Do you have trouble with anesthesia? Y N (if yes explain) List Prior Surgeries, you have had: Date: (Female) Are you pregnant? Y N Date of last Menstrual Period: FAMILY HISTORY List all medical illnesses affecting your immediate family: If deceased -at what age? Mother: Father: Brother: Sister: SOCIAL HISTORY Work status (circle) Full-time Part-time Disabled Retired
Current/previous occupation: How long? Marital Status: (circle) Single Married Separated Divorced Widowed Do you have children? Yes No How Many? Do you smoke? Yes No Former Do you consume alcohol? Yes No How Much? Do you exercise? Yes No How often? GENERAL: Check all that apply REVIEW OF SYSTEMS (CIRCLE OR CHECK ALL THAT APPLY) Fainting Dizziness Fainting Fever Decreased Appetite Weakness HEAD, EYES, EARS, NOSE, THROAT (HEENT): Check all that apply Blurry Vision Hearing Loss Hoarseness Ringing in Ears Sore Throat Total loss of Vision Partial Vision Loss PULMONARY: Check all that apply Coughing up blood Coughing up sputum Cough Short of Breath Wheezing CARDIOVASCULAR: Check all that apply Ankle Swelling Chest Pain Irregular heart beat Leg Pain with Exercise Palpitations GENITOURINARY: Check all that apply Blood in Urine Burning Frequency Hesitancy Urgency Incontinence MUSCULOSKELATAL: Check all that apply
Joint Pain Joint Swelling Joint Stiffness Low Back Pain Muscle Aches Neck Pain/Stiffness GASTROINTESTINAL: Check all that apply Difficulty speaking Heartburn Nausea/Vomiting Vomiting Blood Abdominal Pain Diarrhea Constipation Blood in Stool SKIN: Check all that apply Rash Sores Pruritis (itching) NEUROLOGICAL: Check all that apply Headaches Muscle weakness Numbness PSYCHIATRIC: Check all that apply Feeling restless Anxiety Confusion Depression Sleep disturbance Memory Loss ENDOCRINE: Check all that apply Sensitive to temperatures Excessive thirst HEMATOLOGY/LYMPH: Check all that apply Easy bruising Easy Bleeding Swollen glands
VEIN HISTORY Do you have a history of ulceration's, phlebitis, or deep vein thrombosis (DVT)? Y N How long have you had spider/varicose veins:? Have you ever worn compression hose? Y N If yes, how long? Does prolonged sitting or standing aggravate your veins? Y N Does elevating your legs relieve your symptoms? Y N Do you have any of the following? (Circle or check all that apply) Swelling/Edema Pain Fatigue/Tiredness Ulceration Burning/Itching Throbbing Aching Skin color changes Varicose Veins Spider Veins