Single Married Divorced Widowed Male Female

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Annual Physical Form General Information Name Birth Date Phone Email Address Street Address City State Zip Marital Status Gender Single Married Divorced Widowed Male Female Employment Information Position Employer Phone Employer's Address City State Zip Present Medical History Has a doctor ever said that your blood prerssure is/was too high? Do you ever have pain in your chest or heart? Are you often bothered by a thumping of the heart? Does your heart often race? Do you ever notice extra heart beat or skipped beats? Are your ankles often badly swollen? Do cold hands or feet trouble you even in hot weather? Has a doctor ever said that you have, or have had, heart trouble, an abnormal electrocardiogram ECG or EKG), heart attack, or coronary? Do you suffer from frequent cramps in your legs? Do you often have difficulty breathing? Do you get out of breath long before anyone else? Do you sometimes get out of breath when sitting or sleeping? Has a doctor ever told you that your cholesterol level is/was high? Has a doctor ever told you that you have an abdominal aortic aneurysm? Has a doctor ever told you that you have critical aortic stenosis?

Do you now have, or have you recently experienced, any of the following: Chronic, recurrent or morning cough? Episode of coughing up blood? Increased anxiety or depression? Problems with recurrent fatigue, trouble sleeping or increased irritability? Migraine or recurrent headaches? Swollen or painful knees or ankles? Swollen, stiff, or painful joints? Pain in your legs after walking short distances? Foot problems? Back problems? Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation, or diarrhea? Significant vision or hearing problems? Recent change in a wart or a mole? Glaucoma or increased pressure in the eyes? Exposure to loud noises for long periods? An infection, such as pneumonia, accompanied by a fever? Significant, unexplained weight loss? A fever, which can cause dehydration and rapid heart beat? A deep vein thrombosis (blood clot)? A hernia that is causing symptoms? Foot or ankle sores that won't heal? Persistent pain or problems walking after you have fallen? Eye conditions, such as bleeding in the retina or detached retina? Cataract or lens transplant? Laser treatment or other eye surgery? Women only answer the following: Menstrual period problems? Significant childbirth-related problems? Urine loss when you cough, sneeze, or laugh? Date of last pelvic exam and/or Pap smear: / / Are you on any type of hormone replacement therapy? Yes No

Men and women answer the following: List any prescriptions, self-prescribed medications, dietary supplements, or vitamins you are now takig: Date of last complete physical examination: / / The result was: Normal Abnormal I can't remember I have never had one Date of last chest x-ray: / / The result was: Normal Abnormal I can't remember I have never had one Date of last electrocardiogram (ECG or EKG): / / The result was: Normal Abnormal I can't remember I have never had one Date of last dental checkup: / / The result was: Normal Abnormal I can't remember I have never had one List any other medical or diagnostic test you've had in the past two years: List surgeries and hospitalizations, including dates and reasons: List any drug allergies: Past Medical History Heart attack If yes, how many years ago: Reumatic Fever Heart murmur Diseases of the arteries Varicose veins Arthritis of legs or arms Diabetes or abnormal blood sugar tests Phlebitis (inflamation of a vein) Dizziness or fainting spells Epilepsy or seizures Scarlet Fever Infectious mononucleosis Nervous or emotional problems Anemia Thyroid problems Pneumonia Bronchitis Astma Abnormal chest x-ray Other lung disease Injuries to back, arms, legs, or joint

Past Medical History (continued) Stroke Diptheria Broken bones Jaundice or gall bladder problems Family Medical History My father is: Alive, his current age is: Deceased, age at the time of his death was: If alive, how is his general health: Excellent Good Fair Poor If his health is poor, why? My mother is: Alive, her current age is: Deceased, age at the time of her death was: If alive, how is her general health: Excellent Good Fair Poor If her health is poor, why? Siblings: Number of brothers: Number of sisters: Age range: Health problems: Family Diseases Have any of your blood-relatives had any of the following (include grandparents, aunts, and uncles. Do no include cousins, relatives by marriage, and half-relatives)? Heart attack, under the age of 50 Congenital heart disease (existing at birth but Stroke, under the age of 50 not hereditary) High blood pressure Heart operations Elevated cholesterol Glaucoma Diabetes Obesity (20 or more pounds overweight) Asthma or hay fever Leukemia or cancel, under the age of 60

Other Heart Disease Risk Factors Smoking Have you ever smoked cigarettes, cigars, or a pipe? Yes No (if no, skip to diet section) If you currently, or used to, smoke cigarettes, how many per day? What age did you start? If you currently, or used to, smoke cigars, how many per day? What age did you start? If you currently, or used to, smoke pipes how many per day? What age did you start? If you stopped smoking, when did you stop? If you currently smoke, when did you start? Diet What do you consider a good weight for you? What is the most you have ever weighed? My current weight is: One year ago, my weight was: When I was 21, my weight was: Number of meals you usually eat per day: What age were you? Number of times per week you usually eat the following: Beef: Fish: Desserts: Glasses of water: Pork: Fowl: Fried foods: Do you drink alcoholic beverages? Yes No If yes, how often? Beer: Occasionally Often Never Wine: Occasionally Often Never Hard liquor: Occasionally Often Never Fred J. VonStieff, M.D. Kristi M. Carpenter, D.O. 2481 Pacheco Street, Concord, CA 94520 Ph. (925) 680-8933 Fax (925) 680-7635 Please visit us online at www.vsmedicalgroup.com

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