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)?

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: