Time to complete: 10 minutes

 

Name:

DOB:

Age:

Referring Physician:

Primary Care Physician:

Chief Complaint:

Past Medical History:

Past Surgic History:

Please list allergies of any kind, and include reactions:

Present Medications & Doses:
(Please include all prescription and non-prescription medications.)

Obstetrical History

# of Pregnancies:

# of Children:

Age at first live birth:

Age of menarche:

Age of menopause:

Social History/Habits

Tobacco: YesNo
Type:
Times per day:

Exercise: YesNo
Times per week:
Caffeine:

Alcohol: YesNo
Times per week:

Street Drugs: YesNo

Family History
(Please fill out the fields as they apply and leave blank the ones that do not.)

Father's Age:
Father's Health:
Father's Age at Death:
Cause of Death:

Mother's Age:
Mother's Health:
Mother's Age at Death:
Cause of Death:

Brother/Sister:
Health:
Age at Death:
Cause of Death:

Brother/Sister:
Health:
Age at Death:
Cause of Death:

Select if any blood relatives (mother, father, brother, sister, aunt, uncle, grandfather, grandmother) have had any of the following:

Stroke: YesNo
Cancer: YesNo
High Blood Pressure: YesNo
Tuberculosis: YesNo
Diabetes: YesNo
Leukemia: YesNo
Epilepsy: YesNo
Emphysema: YesNo
Bleeding Tendency: YesNo
Heart Attack: YesNo
Kidney Disease: YesNo
Arthritis: YesNo
Colitis: YesNo
Rheumatic Heart: YesNo
Congenital Heart: YesNo
Died Suddenly: YesNo
Heart Failure: YesNo

 

Please check the appropriate box to indicate if you have or have not had problems with any of the following, and describe in the space provided.

GENERAL HEALTH

Fever: YesNo

Chills: YesNo

Fatigue or Tiredness: YesNo

Cancer: YesNo

Unexplained Weight Loss or Gain: YesNo

EYES

Disease/Injury: YesNo

Blurred Vision: YesNo

Double Vision: YesNo

Glaucoma: YesNo

EARS/NOSE/MOUTH/THROAT

Hearing Loss: YesNo

Ringing in Ears: YesNo

Earaches/Drainage: YesNo

Nosebleeds: YesNo

Chronic Sinus Problems: YesNo

Mouth Sores: YesNo

Sore Throat: YesNo

Voice Changes: YesNo

Swollen Neck Glands: YesNo

CARDIOVASCULAR

Heart Trouble: YesNo

Chest Pain/Angina: YesNo

Rheumatic Fever: YesNo

Irregular or Fast Heartbeat: YesNo

High Blood Pressure: YesNo

Swelling of Feet/Hands: YesNo

RESPIRATORY

Shortness of Breath: YesNo

Coughing: YesNo

Spitting up Blood: YesNo

Asthma/Wheezing: YesNo

GASTROINTESTINAL

Change in Bowel Movements: YesNo

Nausea/Vomiting: YesNo

Frequent Diarrhea: YesNo

Rectal Bleeding/Blood in Stool: YesNo

Abdominal Pain/Heartburn: YesNo

Peptic or Stomach Ulcers: YesNo

Colitis: YesNo

Gallbladder Disease: YesNo

GENITOURINARY

Frequent Urination: YesNo

Burning/Painful Urination: YesNo

Blood in Urine: YesNo

Incontinence or Dribbling: YesNo

Kidney Stones: YesNo

Sexual Difficulty: YesNo

Male -- Testicle Pain: YesNo

Female -- Irregular Periods: YesNo

Female -- Planning Pregnancy: YesNo

Female -- Menopause: YesNo

Sexually Transmitted Disease: YesNo

MUSCULOSKELETAL

Joint Pain: YesNo

Muscle Pain: YesNo

Muscle Weakness: YesNo

Joint Stiffness/Cramping: YesNo

Gout: YesNo

Arthritis: YesNo

SKIN/BREAST

Rash or Itching: YesNo

Change in Skin Color: YesNo

Change in Hair/Nail Color: YesNo

Varicose Veins: YesNo

Breast Pain: YesNo

Female -- Breast Discharge: YesNo

NEUROLOGICAL

Stroke: YesNo

Frequent Headaches: YesNo

Lightheadedness/Dizziness: YesNo

Seizures: YesNo

Numbness/Tingling: YesNo

Tremors: YesNo

Head Injury: YesNo

Blackout/Loss of Consciousness: YesNo

PSYCHIATRIC

Nervousness: YesNo

Depression: YesNo

Insomnia: YesNo

ENDOCRINE

Hormone Problems: YesNo

Thyroid Disease: YesNo

Diabetes: YesNo

Excessive Thirst: YesNo

Excessive Urination: YesNo

Heat/Cold Intolerance: YesNo

Dry Skin: YesNo

HEMATOLOGY/LYMPHATIC

Slow to Heal After Cuts: YesNo

Bleeding/Bruising Tendency: YesNo

Anemia: YesNo

Past Transfusions: YesNo

Enlarged Glands: YesNo

Jaundice: YesNo

Hepatitis: YesNo

ALLERGIC/IMMUNOLOGIC

Food Allergies: YesNo

Environmental Allergies: YesNo

Latex Allergies: YesNo