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NAME:
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AGE
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HEIGHT
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FT INCHES
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WEIGHT LBS
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NAME OF THE DOCTOR WHO ASKED YOU TO SEE US:
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REASON FOR SEEING THE DOCTOR:
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PLEASE LIST YOUR OTHER MEDICAL PROBLEMS (SUCH AS DIABETES, HIGH BLOOD PRESSURE, ETC):
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LIST ALL OPERATIONS/SURGERIES YOU HAVE HAD IN THE PAST AND ANY COMPLICATIONS YOU HAD:
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ARE YOU ALLERGIC TO ANY MEDICATIONS, FOOD OR DRESSINGS? YES NO
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IF YOU ARE, PLEASE GIVE US A LIST :
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ARE YOU ALLERGIC TO LATEX? YES NO
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DO YOU TAKE ASPIRIN FREQUENTLY? YES NO HOW OFTEN? __________________ DO YOU TAKE COUMADIN? YES NO
DO YOU TAKE PREDNISONE OR STEROIDS? YES NO DO YOU TAKE VITAMINS? YES NO
DO YOU TAKE HERBS, ROOTS, MEDICINAL TEA? YES NO PLEASE LIST ALL BELOW
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PLEASE GIVE US A LIST OF ANY MEDICATIONS/VITAMINS/HERBS YOU TAKE ON A REGULAR BASIS
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NAME OF MEDICATION
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DOSE
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HOW MANY TIMES PER DAY
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1 2 3 4 AS NEEDED
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1 2 3 4 AS NEEDED
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1 2 3 4 AS NEEDED
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1 2 3 4 AS NEEDED
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1 2 3 4 AS NEEDED
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1 2 3 4 AS NEEDED
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1 2 3 4 AS NEEDED
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1 2 3 4 AS NEEDED
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SOCIAL HISTORY
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MARITAL STATUS SINGLE MARRIED DIVORCED WIDOW
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OCCUPATION
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DRINK ALCOHOL? YES NO IF YES, HOW MANY DRINKS PER DAY
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SMOKE? YES NO IF YES, HOW MANY PACKS PER DAY
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RECREATIONAL DRUGS? YES NO IF YES, WHICH DRUGS?
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FAMILY HISTORY:
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MOTHER
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FATHER
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OTHER
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CANCER
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DIABETES
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HEART DISEASE
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STROKE
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OTHER:
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(BOTH CURRENT AND OLD PROBLEMS)
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Y
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N
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SYMPTOM
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DESCRIBE
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NEURO
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CONVULSIONS
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MIGRAINE HEADACHES
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STROKES
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PARALYSIS
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CARDIAC
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CHEST PAIN
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SHORTNESS OF BREATH
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HIGH BLOOD PRESSURE
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HEART FAILURE
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HEART ATTACK
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PULMONARY
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CHRONIC COUGH
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SLEEP APNEA / SNORING
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ASTHMA
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RECENT COLDS OR PNEUMONIA
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RENAL
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BLOOD IN URINE
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FREQUENT BLADDER INFECTIONS
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KIDNEY INFECTIONS/DISORDERS
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PAIN WHEN URINATING
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GASTROINTESTINAL
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BLOOD IN STOOL
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VOMITING BLOOD
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BLACK STOOLS
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CHRONIC DIARRHEA
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CHRONIC CONSTIPATION
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BLOATING
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NAUSEA OR VOMITING
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DIFFICULTY SWALLOWING
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PAIN WHEN SWALLOWING
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CHRONIC HEARTBURN / REFLUX
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HEPATITIS
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CIRCLE ONE YOU HAD/HAVE: A B C DONT KNOW
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ULCERS
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PANCREATITIS
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GALLSTONES
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ENDOCRINE
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DIABETES
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THYROID PROBLEMS
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LACK OF ENERGY
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HEMATOLOGIC
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ANEMIA
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EASY BRUISING
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BLOOD CLOTS IN DEEP VEINS OF ARMS/LEGS
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BLOOD TRANSFUSSIONS
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HIV / AIDS?
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VISION
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BLINDNESS
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DOUBLE VISION
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DO YOU WEAR GLASSES OR CONTACT LENSES
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HEARING
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DEAFNESS
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RINGING IN EARS
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SKIN/INTEGUMENT
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SKIN RASHES
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UNUSUAL MOLES
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BREAST LUMPS
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MUSCULAR/SKELETAL
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BACK PAIN
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HIP PAIN
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KNEE PAIN
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OTHER JOINT
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SPECIFY WHICH JOINT
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ARTHRITIS
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PSYCHIATRIC
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DEPRESSION
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ANXIETY
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HALLUCINATION
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CONSTITUTIONAL
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FEVER
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CHILLS
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SWEATS
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WEIGHT LOSS OR GAIN
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HOW MUCH?
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GYNECOLOGY
|
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EVER BEEN PREGNANT?
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HOW MANY TIMES?
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(LADIES ONLY)
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DO YOU HAVE CHILDREN?
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HOW MANY?
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ANY MISCARRIAGES OR ABORTIONS?
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HOW MANY?
|
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AGE WHEN YOU HAD YOUR FIRST PERIOD
|
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DATE OF LAST MENSTRUAL PERIOD
|
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DID YOU BREAST FEED
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IF YES, HOW LONG?
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