Patient History Form

Acct #: Patient History Form Using a black or blue pen, please write clearly and answer ALL questions by filling out the appropriate box(es). Name: Gender: M F Primary Care Provider: Today s Date: What gender do you identify with? DOB: M F Other Referring Provider (if different from PCP): Chief Complaint-Primary reason for today s visit: Length of symptoms: Have you ever been treated by another healthcare provider for current problems? No Yes If yes, please list provider(s): Last menstrual period Are you pregnant? No Yes I am male Do you need special accommodations for your exam? No Yes If yes, please describe: What would you like addressed at today s visit? Current Weight (lbs): Height (in): Page 1 of 9

Current Medications/Supplements/Vitamins What pharmacy do you use? Do you currently take Coumadin (warfarin), Aspirin, Plavix, Pradaxa, Eliquis, or other blood thinners? No Yes If no, have you ever taken Coumadin (warfarin), Aspirin, Plavix, Pradaxa, Eliquis, or other blood thinners? No Yes Do you take any herbal supplements? No Yes Provide a detailed list of medications/supplements/vitamins with doses, OR bring medication bottles to your appointment. Medication Dose How often taken Page 2 of 9

Allergies Do you have any side effects (not allergic reactions) to medications (ie: nausea, vomiting)? Have you ever had an allergic reaction to a medication (ie: rash, itching, trouble breathing)? If yes, please list the medication and the reaction in the boxes below. No Yes No Yes Please list any medication allergies (lidocaine, penicillin, sulfa, etc.). Medication Reaction(s) Other Reaction (describe) Rash Difficulty Breathing Do you have any local anesthesia allergies? No Yes Have you ever had anaphylaxis (a life-threatening allergic reaction)? No Yes Is there any personal or family history of inhaled gas allergy (malignant hyperthermia)? No Yes Do you have an allergy to IV Contrast? No Yes If yes, mark all that apply: CT scan MRI scan Please list any other allergies (nuts, latex, shellfish, eggs, soy, etc.). Other Allergies Reaction(s) Other Reaction (describe) Rash Difficulty Breathing Preventative Care Colonoscopy Flu Vaccine Pneumonia Vaccine No Yes If yes, approximate date No Yes If yes, approximate date No Yes If yes, approximate date Page 3 of 9

Review of Systems Fill in the box if you have had one of these symptoms in the LAST SIX MONTHS. NONE General Ears Nose Throat Hematologic/Lymphatic Fever Sinus congestion Bleeding problems Unintentional weight loss Throat pain/soreness Easy bleeding Chills Easy bruising Respiratory Enlarged lymph nodes Allergy Cough Night sweats Allergy requiring immunotherapy Shortness of breath Anaphylaxis Shortness of breath with exertion Skin Environmental allergy Rash/sores Hay fever Cardiovascular Itchy eyes Ankle/leg/foot swelling Musculoskeletal Postnasal drainage Chest pain Back pain Runny nose Sneezing fits Gastrointestinal Urinary Abdominal pain Blood in urine Neurological Nausea Burning/painful urination Headache Vomiting Flank pain Seizures Frequent urination Incomplete emptying Eyes Involuntary/unintended urine loss Blurring Strong urgency to urinate Urine loss when coughing or lifting Other symptom(s) not listed above: Page 4 of 9

Your Medical History Please indicate whether you have or have had any of the following by filling in the appropriate box(es). NONE Respiratory Neurological Musculoskeletal Cardiovascular Asthma Alzheimer s Back pain Arrhythmia Blood clots in the lung Aneurysm Broken bones Blood clots in leg Bronchitis Migraine headache Fibromyalgia Clot in vein Emphysema/COPD Multiple sclerosis Osteoarthritis Congestive heart failure Pneumonia Parkinson s Scoliosis Deep vein thrombosis Sleep apnea Seizure disorder Heart attack Tuberculosis Stroke or TIA Cancer Heart murmur Anal High blood pressure Gastrointestinal Genitourinary/GYN Brain High cholesterol Colon polyp Abnormal pap Breast Peripheral artery Crohn s disease Breast disease Cervical disease Diverticulitis Kidney disease Colon Phlebitis Gallbladder disease Kidney stones Esophageal Pulmonary embolus GERD (reflux) Ovarian disease Head and neck Hepatitis Pelvic organ prolapse Kidney Psychological Irritable bowel syndrome Prostate Leukemia ADHD Liver disease Sexual abuse Liver Alcohol dependence Pancreatitis Sexually transmitted Lung Anxiety Ulcerative colitis diseases Lymph node Bipolar Ulcers Uterine/Cervical disease Ovary Depression Pancreas Drug dependence Endocrine Eyes Prostate Eating disorder Adrenal disorders Cataracts Rectal Other mental illness Amyloidosis Glasses/contacts Skin Diabetes Glaucoma Stomach Infections High calcium level in Thyroid C-difficile blood Hematologic/Lymphatic Uterine (endometrial) HIV/AIDS Osteoporosis Anemia Other cancer Herpes (genital) Pituitary disorders Bleeding disorders Herpes (oral) Thyroid disorders Blood transfusion Rheumatologic Persistent infections Coagulation disorders Autoimmune disease Spleen injury Lupus Other arthritis Rheumatoid arthritis Vasculitis Other disorder(s) not listed above: Have you ever had radiation treatment? No Yes Page 5 of 9

Past Surgical History Please indicate whether you have ever had a surgery on the following area by filling in the appropriate box(es). NONE Please give the most recent date for each. Type of Surgery Specify if Type is too Date or Year General of Surgery Facility Eyes Ears Nose Sinuses Tonsils Adenoids Thyroid Parathyroid Arteries (stent or bypass) Veins Coronary (heart) artery stent Coronary artery bypass Heart valve Other heart surgery Lung Esophagus Stomach Bowel (small or large intestine or rectum) Gallbladder Pancreas Spleen Appendix Hernia Kidneys Urinary bladder Bones Joints Muscles Spine Brain Skin Female Breasts Uterus Ovaries Fallopian tubes Hysterectomy Caesarean section Other female surgery Continued on next page Page 6 of 9

Male Prostate Penis Testicles Vasectomy Other male surgery Any other surgery not listed Have you ever had complications from a surgery? No Yes (Please describe) Have you ever had general anesthesia (breathing tube)? No Yes If yes, were there complications? No Yes (Please describe) Have you ever had IV conscious sedation (no breathing tube)? No Yes If yes, were there complications? No Yes (Please describe) Procedures Please indicate if you have had any of the following procedures: Type Date Facility CT Scan MRI Scan PET Scan Ultrasound X-rays Social History Occupation (current/former): Currently Employed? If no, what is your current status? Marital status? Do you exercise regularly? What is your current living situation? Live with: (mark all that apply): Children: Full Time Part Time No Lifting requirement at work lbs Homemaker Disabled Retired Student-Highest year of education Other: Single Married Partnered Separated/Divorced Widowed Since what year? No Yes If, yes, type of exercise : Page 7 of 9 Days per week: Minutes per day: Spouse/Partner Children Parents Alone Care Facility Friends Other: # Living Sex, Ages, Health # Deceased Sex, Ages, Health

Patient Habits Caffeine Do you drink caffeinated beverages? No Yes If yes, how many per day? Tobacco/Nicotine Smoking status: Current every day smoker Current some day smoker Light tobacco smoker Heavy tobacco smoker Former Never If current or former smoker, how many packs per day? What year did you start? If former smoker, what year did you quit? Have you ever used other tobacco or nicotine products? No Yes If yes, what type? Pipe Cigars Chewing Tobacco e-cigarette Other (please specify) How much per day? What year did you start? Have you quit? No Yes If yes, what year did you quit? Alcohol Have you ever consumed alcohol? No Yes If yes, on average, how many drinks per week? What year did you start? Have you quit? No Yes If yes, what year did you quit? Marijuana/Recreational Drugs Have you ever used marijuana, IV or other recreational drugs? No Yes If yes, what type? Marijuana Crack/Cocaine Methamphetamines Heroin Other (please specify) Do you have a medical marijuana card? No Yes Have you ever used by IV, by needle, or by inhaling up your nose? No Yes What year did you start? Have you quit? No Yes If yes, what year did you quit? Page 8 of 9

Family History Does anyone in your family have a history of any of the following? Mother Father Brother Sister Daughter Son NONE Hematologic/Other Bleeding disorder Anesthesia problems Genitourinary diseases Bladder cancer Kidney cancer Kidney stones Kidney infections Bladder infections Prostate cancer Uterine cancer Additional Family History comments: Are you adopted? Father: Mother: No Alive Deceased Don t know Alive Deceased Don t know Yes If deceased, cause of death: If deceased, cause of death Don t know Age of Death Under 30 30-50 51-70 Over 70 Age of Death Under 30 30-50 51-70 Over 70 Patient Signature: Date: Page 9 of 9