PATIENT INFORMATION FORM (WOMEN ONLY)

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Transcription:

PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for which you are now under treatment and list all medications you are currently taking: C. 1. Please check any of the following illnesses which you have had stating year of occurrence if possible: o Arthritis (yr: ) o Asthma (yr: ) o Bronchitis (yr: ) o Cancer (yr: ) o Chickenpox (yr: ) o Diabetes (yr: ) o Eczema (yr: ) o Epilepsy (yr: ) o Gall Bladder Disease (yr: ) o German Measles (yr: ) o Gout (yr: ) o Hay Fever (yr: ) o Heart Disease (yr: ) o Hepatitis (yr: ) o Hives (yr: ) o Hypertension (yr: ) o Malaria (yr: ) o Measles (yr: ) o Meningitis (yr: ) o Migraine (yr: ) o Mumps (yr: ) o Nephritis (yr: ) o Phlebitis (yr: ) o Pleurisy (yr: ) o Pneumonia (yr: ) o Poliomyelitis (yr: ) o Renal Stones (yr: ) o Rheumatic Fever (yr: ) o Sexually Transmitted Disease (yr: ) o Sinusitis (yr: ) o Thyroid (yr: ) o Typhoid (yr: ) o TB (yr: ) o Tonsillitis (yr: ) o Ulcers (yr: ) o Any other: (yr: ) 1 of 6

C. 2. If you have had any of the following, state the year of occurrence, site and/or problem: Condition Year Site Problem/ Note Hernias Concussions Fractures Dislocations Sprains and Strains C. 3. Name any illness, injury or disability not mentioned above and state year of occurrence: C. 4. Have you ever smoked? Yes No C. 5. Have you ever had X-Ray therapy such as for acne, Large Tonsils, etc? Yes No C. 6. a. Have you ever consumed 3 or more cups of coffee or caffeine-containing beverage? Yes No C. 6. b. Have you ever consumed alcohol? Yes No If yes, describe how much and how often: C. 7. If you have ever been hospitalized, state: Date Hospital Name Hospital Location Illness/ Injury/ Operation C. 8. Have you ever received or are you receiving disability compensation? Yes No D. If you have now, or have had any of the following symptoms or conditions, please check and underline or describe the problem. If not, leave unchecked: o Recent changes in weight o Insomnia (difficult to sleep) o Fatigue, nervousness, worry or emotional disturbance that have caused loss of time from work or study o Prolonged fever o Dizziness, loss of consciousness or headaches o Eye, Ear, Nose, Throat or Sinus symptoms 2 of 6

continued... o Impairment of sight, hearing or speech o Chronic cough, coughing up blood or exposure to TB o Chest pain, shortness of breath, palpitation, swollen ankles, heart murmur, high blood pressure o Leg cramps, varicose veins, varicose ulcers o Troublesome skin condition, i.e. hair loss, facial hair growth, rash or itching o Bleeding problems o Symptoms related to the gastrointestinal tract, i.e. recurring abdominal pain, indigestion, diarrhea, passing of blood etc. o Albumin, sugar or blood in urine, kidney stone or other urinary difficulties o Muscle, joint or back pain, bursitis sciatica o Benign or malignant growth or tumor o Thyroid problems of any kind o If any goiter, thyroid lump or any nodule, please answer the following questions along with any description o Any exposure to radiation in the past? o Any difficulty in swallowing, breathing or hoarseness of voice? o Any rapid growth or pain in the thyroid swelling? E. If any sensitivities (allergies) to penicillin, sulfa or other drugs or allergens: Yes No If yes, specify F. For Women Only: Age at Onset Age at Cessation Circle: Pain: Yes No If Yes: Mild Moderate Severe Length of Cycle: Bleeding between periods Yes No Duration: Abnormal discharge or itching Yes No Self breast examination: 3 of 6

Do you self examine the breast regularly? Yes No Have you noticed any soreness, lumps or nipple discharge? Yes No Have you noticed any change in tissue? Yes No Have you had a mammogram? Yes No If Yes, date / / Place: Have you had Pelvic and Pap smear done? Yes No If Yes, date / / By whom: Date of last menstrual period G. [OMITTED] H. Family history Relative Year of Birth Occupation State of Health 1. Father 2. Mother 3. Brothers Are brothers in good health? Yes No If no, describe 4. Sisters Are sisters in good health? Yes No If no, describe 5. If you are married, give year of birth and state of health of the spouse: 6. If any children, give their ages: Are they in good health? Yes No If no, describe If family member is not living, give cause of death, age and year of occurrence: 7. Has any blood relative had cancer, diabetes, high blood pressure, heart disease, thyroid disease, epilepsy, migraine, bleeding disorders, allergy, tuberculosis, stroke, anemia, neurological disorder, muscular dysfunction or emotional disturbance, hepatitis, AIDS, leukemia, stomach ulcer, kidney disease, arthritis, sexual dysfunction, cholesterol problem or kidney stones? 4 of 6

Yes No If Yes, indicate relative and illness: Relation Illness 8. Do you know if your mother took estrogens (such as DES) while you were in Utero? Yes No 9. Has any blood relative had breast cancer? Yes No colon cancer? Yes No thyroid cancer? Yes No pituitary, adrenal or pancreatic cancer? Yes No I. Your birthplace: List any countries outside the USA or Canada which you have visited J. Give year for the following immunizations and tests: Diphtheria Tetanus Measles Rubella Hepatitis B Pneumonia Last blood test Poliomyelitis Tuberculin skin test Circle Reaction Positive Negative Last chest X-ray Last EKG Last thyroid test K. When was the last physical examination done? / / By whom: L. When was the last eye examination done? / / By whom: M. When was the last foot examination done? / / By whom: N. When was the last chest X-ray done? / / By whom: O. When was the last EKG done? / / By whom: P. Please provide any other significant information relating to your health (Additional Note): 5 of 6

DATE: SIGNATURE: Please hand this questionnaire to the medical receptionist after completion. If you realize after you complete this form that any information herein needs to be corrected or updated, please advise our office immediately. Thank you for your cooperation. 6 of 6

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