Maineville Family Physician. History and Review of Systems. Name: DOB

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Maineville Family Physician History and Review of Systems Name: DOB History of Medical Problems: Please circle the conditions which you have been diagnosed with by a physician and the year or age you were when diagnosed. ADHD, with or without hyperactivity (please circle which one) Alcoholism Allergic rhinitis Alzheimer s disease Anemia Asthma Cancer, what type? Carotid Stenosis (narrowing of the arteries in the neck) Cataracts Cerebrovascular Accident (stroke) Cervical disc disease (herniated discs in neck) Congestive Heart Failure (CHF) COPD (emphysema) Colonic polyps (ployps in the colon) Coronary artery disease (clogged heart arteries) Myocardial infarction (MI or heart attack) Crohn s disease Deep Venous Thrombosis (DVT) (blood clot in leg requiring Coumadin) Dementia Diabetes mellitus, type 2 (adult onset) Diabetes mellitus, type 1 (child onset) Eczema Fibromyalgia GERD/hiatal hernia/pud (ulcers) Glaucoma Gout Hemorrhoids Hyperlipidemia (high cholesterol) Hypertension (high blood pressure) Hypothyroidism (low thyroid function) Irritable Bowel Syndrome (IBS) Kidney disease Kidney Stones Liver disease Lumbar Disc Disease (herniated discs in low back) Lumbar Spinal Stenosis (narrowing of spinal canal in low back)

Lupus (SLE) Macular Degeneration Migraine headache Obesity Osteoarthritis (arthritis form overuse or aging) Osteoporosis Parkinson s Disease Peripheral artery disease (arterial blockage in legs or aorta) Pulmonary Embolism (blood clot to the lung) Psoriasis Rheumatoid arthritis Seizure disorder (epilepsy) Sleep apnea Subarachnoid hemorrhage (bleeding brain aneurysm) TMJ syndrome Ulcerative Colitis Venous Stasis (swelling in legs due to poorly functioning veins) Mental Illness Bipolar disorder (manic depressive disorder) Depression Suicide attempt(s) Generalized Anxiety disorder Mental retardation/ Developmental Delay Obsessive Compulsive Disorder (OCD) Panic Disorder Post-traumatic stress disorder (PTSD) Schizophrenia Other mental illness Conditions for Men Only Benign Prostatic Hypertrophy (BPH) Elevated PSA Erectile dysfunction (ED or impotence) Genital Herpes Prostatitis Other

Conditions for Women Only Benign breast lump Cervical Dysplasia Dysmenorrhea (abnormally painful periods) Endometriosis Fibrocytic breast change Genital herpes Premenstrual Dysphoria Disorder (PMDD) Other Surgical History Please circle the surgeries you have had and write the year completed or your age when surgery was performed. Never had any surgery (Skip to Family History) Orthopedic Surgery Age or time of surgery Arthroscopic surgery (scope of the knee? Shoulder? Elbow? Which side Right, Left, or Both? Bunionectomy (removal of bunions) Right? Left? Or Both? Carpal Tunnel release? Right? Left? Or Both? Ganglion Cyst surgery? Right, Left, or Both ORIF (open reduction and internal fixation-plates, screws or pins for broken bones) which bone? Right, Left or both Spine surgery of neck? Low Back? Total Joint Replacement of Knee? Hip? Right? Left? Both? Other orthopedic surgery not mentioned? Surgery for Women Only/ Year or age at diagnosis Breast biopsy Benign (no cancer)? Right or left or both? Brest augmentation or reduction Bilateral Tubal Ligation: (tubes tied) C-Section for what reason? D&C (cleaning out uterus) why? Endometrial ablation? (Burning out the lining of the uterus to stop periods) Laparoscopic surgery why? LEEP surgery (partial removal of cervix for abnormal PAP smears) Total Abdominal Hysterectomy with or without removal of right or left or both ovaries? Why? Any Cancer? Vaginal Hysterectomy with or without removal of Other female surgery?

Surgery for Men Only/ Year or age at diagnosis Breast biopsy Prostatectomy (removal of prostate) Prostate biopsies? TURP (remaining procedure of enlarged prostate) Testicular surgery Vasectomy Other male surgery General Surgeries/Year or age at diagnosis Appendectomy (appendix out) Angioplasty with/ without coronary artery stent? CABG (cardiac bypass surgery) If so, how many vessels were bypassed? Cancer Surgery Carotid Endarterectomy (removing plaque buildup in carotid arteries due to blockage) Cataract Surgery, Right, Left, or Both? Cholecystectomy (gallbladder removed) laparoscopic or open? Gastric bypass, which kind? Hemorrhoidectomy Hernia repair, right or left or both sides? Inguinal or ventral or umbilical? Surgical procedures to pen up blocked blood vessels in the arteries? Which kind? Ear tubes? Sinus surgery to pen up sinuses? Deviated septum? Tonsillectomy Adenoidectomy Thyroidectomy Wisdom teeth extraction under general anesthesia (put totally asleep) Other surgery not mentioned? Non-Surgical Testing Procedures/ Year or age procedure was completed Cardiac Catheterization (angiogram) Cardiac stress test Colonoscopy Dexascan (bone density scan) EGD (stomach scope) MRI of brain? Neck? Low back? Other? Occupational Injuries BWC cases? Date of Injury? Is the Case Open?

Allergies please list below Medications please list below Family History Please complete your family s medical history. Please write in any significant medical conditons for each family member. Conditions could include cancer (indicate which kind), heart attack or heart disease, high cholesterol, high blood pressure (HTN), diabetes, adult onset vs child, COPD (emphysema), etc If your family member is deceased, please circle that option and indicate at what age they died and what medical condition they died of. Mother: Conditions? If deceased what age and condition? Father: Conditions? If deceased what age and condition? Maternal Grandmother: Conditions? If deceased what age and condition? Paternal Grandmother: Conditions? If deceased what age and condition? Maternal Grandfather: Conditions? If deceased what age and condition? Paternal Grandfather: Conditions? If deceased what age and condition?

Family History Continued Brothers: Conditions? if deceased, at what age? Sisters: Conditions? If deceased, at what age? Sons: Conditions? If deceased, at what age? Daughters: Conditions? If deceased at what ager? Other? Social History Do you smoke? Yes No Use to Years Smoking? Packs per day? When did you quit? Symptoms of nicotine addictions? Yes or No Desire to quit? Yes or No Do you drink alcoholic beverages? Never Occasional (1-2 drinks per day or less) Moderate (>14 drinks per week) Heavy (> 6 drinks per day) Do you use illicit drugs? No/ marijuana/cocaine/hallucinogens/narcotics Occupation? Student/homemaker/retired/employed part-time/employed full time/ unemployed If applicable What kind of work do you do? Where do you work?

Social History Continued Marital Status: Single Married Engaged Widowed Divorced Involved in an opposite sex relationship/ Involved in same sex relationship. Children: None or Names and month/ year born Who do you live with? I live alone Spouse Children Siblings Parents Father Mother Significant Others

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