Department of Date of appointment / / (mm/dd/yyyy) Please fill this form out as completely as possible and bring this to your appointment. Present Illness Briefly describe the date of onset of your illness and your symptoms Referring Physicians Please check one of the following boxes and provide information on all physicians involved in your care: I was referred by one of the physicians below I referred myself with my physician s knowledge I was referred for a second opinion by my physician I referred myself without my physician s knowledge City State Zip City State Zip Telephone Number: ( ) Telephone Number: ( ) City State Zip City State Zip Telephone Number: ( ) Telephone Number: ( ) Past Medical History (Check any medical problems you have had in the past) Arthritis Congestive heart failure Hypertension (high blood pressure) Asthma COPD (lung disease) Stroke Blood transfusion Coronary artery disease Thyroid disease Cancer Diabetes mellitus Other Page 1 of 6
Department of Past Surgical History (Check any surgeries you have had and the date of surgery if you know it) Abdomen surgery Eye surgery Joint replacement Appendectomy Fracture surgery Kidney transplant Back surgery Gastrectomy Mastectomy Brain surgery Heart surgery Skin biopsy Breast surgery Hernia repair Tonsillectomy Colon surgery Hysterectomy Vascular surgery Cosmetic surgery Surgery for heartburn Esophageal Surgery Chest surgery Lung Surgery Other Family History Check below to report problems your family members have had. Please state the age when they had the problem if you know it. I was adopted so I do not know my family history. Mother Father Sister Brother Daughter Son Other (specify) Alcohol abuse Aneurysm Asthma Autoimmune disease Birth defects Breast cancer Cancer Colon cancer COPD (lung disease) Deep vein thrombosis Dementia Depression Diabetes Heart disease High cholesterol Hypertension Kidney disease Mental illness Osteoporosis Prostate cancer Pulmonary embolism Stroke Thyroid disease Lung cancer Esophageal cancer Other (specify) Alive (Yes, No or Age at death) Page 2 of 6
Department of Social History Marital Status: Divorced Legally Separated Married Significant other Single Widowed Unknown Other (specify): If married, for how long? Employment History: Currently employed Occupation: Employer: Unemployed Retired (Date): Disabled (Date): Previous occupation: What level of education have you attained? Grade school High school College Professional Have you traveled outside of the U.S.? No Yes If yes, where? when? Have you ever served in the military? No Yes If yes, which branch? With whom do you live? Do you have difficulty dressing yourself? No Yes Do you have difficulty carrying a 10lb. bag or shopping? No I live alone Yes Have you ever fallen at home? No Yes If yes, when? Are you receiving any special help at home? No Yes If yes, who helps you? _ Do you follow any special diet? No Vegetarian Kosher Low fat Other: Do you drink coffee? Yes No If yes, how many cups per day do you drink? Do you ever drink alcohol? Yes No If yes, please indicate the quantity per week of each: Glasses of wine Cans/bottles of beer Shots of liquor Drinks containing 0.5 oz of alcohol Are you sexually active? Yes No Not currently If yes, is/are your partner(s): Male Female Both Type of birth control/protection currently used: Abstinence Condom Injection IUD (Intrauterine device) Oral Contraceptive (Pill) Patch Post-menopausal Other None Do you use drugs? Yes No If you use drugs, how many times per week? What type(s) of drugs do you use? Check one of the following about smoking tobacco: Never smoked Former smoker Smoke some days Smoke every day Exposed to second hand smoke If you smoke or used to smoke, how many packs do/did you smoke per day? Page 3 of 6
Department of How many years did you smoke/have you smoked? If you quit, when did you quit? Do you use smokeless tobacco? (Select one below) Former user Current user Never used If you quit, when did you quit? Are you ready to quit smoking and / or using smokeless tobacco? Yes No Gynecologic/Obstetrical History (Women Only) What is/was the last date your period began? Have you stopped having your menstrual periods? No Yes If so, when? Are you now or have you ever been on estrogen (hormone) replacement? No Yes Review of Symptoms: Please indicate if you have now or have ever experienced any of the following symptoms (check all that apply) SYMPTOM WHEN SYMPTOM WHEN Infections Hemorrhoids Now In Past Mumps Now In Past Jaundice Now In Past German measles Now In Past Hepatitis Now In Past Rheumatic fever Now In Past Cirrhosis Now In Past Rubella Now In Past Liver problems Now In Past Mononucleosis Now In Past Blood transfusions Now In Past Polio Now In Past Gallbladder trouble Now In Past Malaria Now In Past Urine Typhoid fever Now In Past Blood in urine Now In Past Shingles Now In Past Sugar in urine Now In Past Gonorrhea Now In Past Albumin/protein in urine Now In Past Syphilis Now In Past Cloudy urine Now In Past Skin Kidney stones Now In Past Rashes Now In Past Prostate (men only) Tumors/unusual moles Now In Past Slow urine stream Now In Past Psoriasis/eczema (circle one) Now In Past Urination at night: (# of times ) Now In Past Hair loss Now In Past Circulation/Vascular Eye Leg pain with walking Now In Past Eye infection/pink eye Now In Past Poor circulation Now In Past Page 4 of 6
Department of Blurred vision Now In Past Varicose veins Now In Past Cataracts Now In Past Muscles/Joints Glaucoma Now In Past Back/bone pain Now In Past Ears Arthritis/rheumatism Now In Past Earache/discharge from ear(s) Now In Past Joint pains/deformity/redness Now In Past Ringing in the ears Now In Past Pain with weather changes Now In Past Spinning sensation/vertigo Now In Past Finger changing colors Now In Past Hearing loss Now In Past Drainage from joints Now In Past Nose and Mouth Locking joints Now In Past Sinus trouble Now In Past Muscle aches/stiffness Now In Past Nosebleeds Now In Past Motion limitation Now In Past Bleeding gums Now In Past Reproduction Sore tongue Now In Past Pain with intercourse Now In Past Teeth trouble Now In Past Impotence/loss of libido Now In Past Lymph Neurological Lumps in groin(s) Now In Past Paralysis Now In Past Neck swelling Now In Past Numbness/tingling of feet/hands Now In Past Lumps in armpits Now In Past Difficulty walking Now In Past Breasts Coordination problem/clumsiness Now In Past Lumps/pain in breast(s) Now In Past Speech/memory problems Now In Past Nipple discharge Now In Past Loss of bowel/bladder control Now In Past Gastrointestinal Dizziness/fainting spells Now In Past Ulcers/stomach trouble Now In Past Epilepsy/seizures Now In Past Black/tarry bowel movements Now In Past Psychological Bright red bowel movements Now In Past Excessive worry/nervousness Now In Past Unusual constipation Now In Past Depression/nervous disorder Now In Past Unusual diarrhea Now In Past Personality disorder Now In Past Change in stool size Now In Past Endocrine Change in stool color Now In Past Thyroid problems Now In Past Change in stool frequency Now In Past Head/cold intolerance (circle one) Now In Past Indigestion/ gas Now In Past Unusual thirst/appetite Now In Past Page 5 of 6
Department of Abdominal pain Now In Past Hand/foot swelling/enlargement Now In Past Respiratory Esophageal New/changing cough Now In Past Difficulty swallowing Now In Past Phlegm/sputum production: Now In Past Food sticking Now In Past (Circle one) Clear white green brown bloody Pain with swallowing Now In Past Hoarseness/change in voice Now In Past Regurgitation of food Now In Past Wheezing Now In Past Nausea/vomiting Now In Past Asthma Now In Past Vomiting blood Now In Past Emphysema Now In Past Ulcers/stomach trouble Now In Past Pneumonia Now In Past Loss of appetite Now In Past Tuberculosis Now In Past Weight loss: lbs. Now In Past Pleurisy Now In Past Weight gain: lbs. Now In Past Shortness of breath w/exertion Now In Past Fever Now In Past Shortness of breath at rest Now In Past Night sweats Now In Past Chest pain Now In Past Cardiac Headaches Now In Past Chest pressure/tightness Now In Past Weakness/fatigue Now In Past Fast/irregular heart beats Now In Past Pain/aches in joints Now In Past Palpitations Now In Past Other Now In Past Heart murmur Now In Past Ankle swelling Now In Past Difficulty breathing at rest Now In Past Difficulty breathing lying down Now In Past _ Printed name of person who completed this form / / (mm/dd/yyyy) Date Page 6 of 6