Title Page

  • Hospital/Clinic

  • Conducted on

  • Prepared by

  • Location

Medical History

General Information

  • Name

  • Birth date

  • Age

  • Sex

  • Contact phone numbers

  • Briefly describe your present symptoms

  • Please list other physicians you have seen in the last 12 months, and for what reason.

Current Medications

  • Drug allergies?

  • To what:

  • Medications that you are now taking. Include non-prescription medications & vitamins or supplements.

Medical History

  • Do you now or have you ever had:

  • Diabetes

  • High blood pressure

  • High cholesterol

  • Hypothyroidism

  • Goiter

  • Cancer

  • Type:

  • Leukemia

  • Psoriasis

  • Psychiatric condition

  • Type:

  • Angina

  • Heart problems

  • Heart murmur

  • Pneumonia

  • Pulmonary embolism

  • Asthma

  • Emphysema

  • Stroke

  • Epilepsy (seizures)

  • Cataracts

  • Glaucoma

  • Kidney disease

  • Kidney stones

  • Crohn’s disease

  • Colitis

  • Anemia

  • Jaundice

  • Hepatitis

  • Stomach or peptic ulcer

  • Varicose veins

  • Environmental allergies

  • Blood clots

  • Serious trauma

  • Sexually transmitted infection

  • Other:

Personal History

  • Childhood Illness

  • Immunizations?

  • Tetanus

  • Date of immunization

  • Pneumonia

  • Date of immunization

  • Hepatitis A

  • Date of immunization

  • Hepatitis B

  • Date of immunization

  • Chickenpox

  • Date of immunization

  • Influenza

  • Date of immunization

  • MMR (Measles, Mumps, Rubella)

  • Date of immunization

  • Meningococcal

  • Date of immunization

  • Any surgeries?

  • Please provide the year/reason/hospital

  • Have you ever had a blood transfusion?

  • Where were you born & raised?

  • What is your highest education?

  • Marital status

  • What is your current or past occupation?

Family History

  • Family history is:

  • Please indicate if your family has a history of the following: (include only parents, grandparents, siblings, and children)

  • Alcohol Abuse

  • Anemia

  • Anesthetic Complication

  • Arthritis

  • Asthma

  • Bladder Problems

  • Bleeding Disease

  • Breast Cancer

  • Colon Cancer

  • Depression

  • Diabetes

  • Heart Disease

  • High Blood Pressure

  • High Cholesterol

  • Kidney Disease

  • Leukemia

  • Lung/Respiratory Disease

  • Migraines

  • Osteoporosis

  • Other Cancer

  • Rectal Cancer

  • Seizures/Convulsions

  • Severe Allergy

  • Stroke/CVA of the Brain

  • Thyroid Problems

  • Mother, Grandmother, or Sister developed heart disease before the age of 65

  • Father, Grandfather, or Brother developed heart disease before the age of 55

  • NONE of the Above

Review of Systems

  • Please indicate with a check (√) any current problems you have below.

Constitutional

  • Fevers/chills/sweats

  • Unexplained weight loss/gain

  • Fatigue/weakness

  • Excessive thirst or urination

  • Other

  • Please describe other

Cardiovascular

  • Chest pain/discomfort

  • Leg pain with exercise

  • Heart murmur or heart problems

  • Palpitations

  • Other

  • Please describe other

Chest

  • Breast lump/discharge

  • Other

  • Please describe other

Ears/Nose/Throat/Mouth

  • Difficulty hearing/ringing in ears

  • Hay fever/allergies

  • Problems with teeth/gums

  • Difficulty swallowing

  • Difficulty with speech

  • Other

  • Please describe other

Endocrine

  • Hypothyroid

  • Hyperthyroid

  • Abnormal hormone levels

  • Abnormal blood glucose levels

  • Other

  • Please describe other

Eyes

  • Changes in vision

  • Farsighted

  • Nearsighted

  • Other

  • Please describe other

Gastrointestinal

  • Abdominal pain

  • Blood in bowel movement

  • Nausea/vomiting/diarrhea

  • Other

  • Please describe other

Genitourinary

  • Nighttime urination

  • Incontinence

  • Sexual function problems

  • Discharge from penis

  • Other

  • Please describe other

Gynecological

  • Abnormal vaginal bleeding

  • Problems with conceiving

  • Problems with contraception

  • Vaginal discharge

  • Vaginal odor

  • Painful intercourse

  • Other

  • Please describe other

Lymphatic/Blood

  • Unexplained lumps

  • Easy bruising/bleeding

  • Anemia

  • Other

  • Please describe other

Musculo-skeletal

  • Muscle/joint pain

  • Arthritis

  • Other

  • Please describe other

Neurological

  • Headaches

  • Dizziness/light-headedness

  • Numbness

  • Memory loss

  • Loss of coordination

  • Epilepsy or convulsive seizures

  • Other

  • Please describe other

Psychiatric

  • Anxiety/stress

  • Problems with sleep

  • Depression

  • Suicidal ideations

  • Other

  • Please describe other

Respiratory

  • Cough/wheeze

  • Difficulty breathing

  • Asthma

  • COPD

  • Sleep apnea

  • Other

  • Please describe other

Skin

  • Rash or mole change(s)

  • Psoriasis

  • Eczema

  • Other

  • Please describe other

Women/Men's Health

  • Male or Female?

  • Gynecologic History

  • Do you have a period every month?

  • Number of days of flow

  • Menstrual cramps

  • Date of last PAP smear

  • Last PAP smear result

  • Have you ever had an abnormal PAP smears?

  • If yes, explain clinical history (including test location, date, what was done) for any abnormal PAP smear:

  • Number of pregnancies

  • Are you presently trying to become pregnant or will be trying soon?

  • Gynecologic symptoms:

  • • Abnormal menstrual bleeding

  • • Missed periods

  • • Night sweats

  • • Hot flashes

  • • Vaginal dryness

  • • History of prescription hormone use

  • • Mood changes associated with period

  • • Insomnia

  • Have you ever had a mammogram?

  • If applicable, indicate the date and result of your last mammogram:

  • Do you usually get up to urinate during the night?

  • Do you feel pain or burning with urination?

  • Any blood in our urine?

  • Do you feel burning discharge from penis?

  • Has the force of your urination decreased?

  • Have you had any kidney, bladder, or prostrate infections within the last 12 months?

  • Do you have any problems emptying your bladder completely?

  • Any difficulty with erection or ejaculation?

  • Any testicle pain or swelling?

  • Date of last prostate and rectal exam

Sexual History

  • Have you ever been sexually active?

  • Are you currently sexually active?

  • Complete the following questions if you are sexually active.

  • Are you currently having sexual relations with one partner or multiple partners?

  • Number of partners in last year

  • Are you in a monogamous relationship?

  • Are/Is your sexual partner(s)

  • Do you and your partner use contraceptive and/or protective methods?

  • Have you ever had a sexually transmitted illness (STI) (i.e. HPV, Herpes, Chlamydia, Gonorrhea or other)? <br>

  • List STI:

  • Treated

Mental Health

  • Is stress a major problem for you?

  • Do you feel depressed?

  • Do you panic when stressed?

  • Do you have problems with eating or your appetite?

  • Do you cry frequently?

  • Have you ever attempted suicide?

  • Have you ever seriously thought about hurting yourself?

  • Do you have trouble sleeping?

  • Have you ever been to a counselor?

  • Patient Name and Signature here:

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