Time to complete: 10 minutes





    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
    Times per day:

    Exercise: YesNo
    Times per week:

    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:

    Age at Death:
    Cause of Death:

    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.


    Fever: YesNo

    Chills: YesNo

    Fatigue or Tiredness: YesNo

    Cancer: YesNo

    Unexplained Weight Loss or Gain: YesNo


    Disease/Injury: YesNo

    Blurred Vision: YesNo

    Double Vision: YesNo

    Glaucoma: YesNo


    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


    Heart Trouble: YesNo

    Chest Pain/Angina: YesNo

    Rheumatic Fever: YesNo

    Irregular or Fast Heartbeat: YesNo

    High Blood Pressure: YesNo

    Swelling of Feet/Hands: YesNo


    Shortness of Breath: YesNo

    Coughing: YesNo

    Spitting up Blood: YesNo

    Asthma/Wheezing: YesNo


    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


    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


    Joint Pain: YesNo

    Muscle Pain: YesNo

    Muscle Weakness: YesNo

    Joint Stiffness/Cramping: YesNo

    Gout: YesNo

    Arthritis: YesNo


    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


    Stroke: YesNo

    Frequent Headaches: YesNo

    Lightheadedness/Dizziness: YesNo

    Seizures: YesNo

    Numbness/Tingling: YesNo

    Tremors: YesNo

    Head Injury: YesNo

    Blackout/Loss of Consciousness: YesNo


    Nervousness: YesNo

    Depression: YesNo

    Insomnia: YesNo


    Hormone Problems: YesNo

    Thyroid Disease: YesNo

    Diabetes: YesNo

    Excessive Thirst: YesNo

    Excessive Urination: YesNo

    Heat/Cold Intolerance: YesNo

    Dry Skin: YesNo


    Slow to Heal After Cuts: YesNo

    Bleeding/Bruising Tendency: YesNo

    Anemia: YesNo

    Past Transfusions: YesNo

    Enlarged Glands: YesNo

    Jaundice: YesNo

    Hepatitis: YesNo


    Food Allergies: YesNo

    Environmental Allergies: YesNo

    Latex Allergies: YesNo