Medical History

Medical History

Last Name ________________________First Name___________________Initial______Age_____Acc#_______

Today's Date___/___/___ Birth Date___/___/___ Ref.Physician___________________Office (circle one) V H S

Please give us your medical history by completing Following:

Chief Complaint (CC) (What is your current complaint?):______________________________________________________

History of Present Illness (HPI) (To be completed by medical assistant or doctor):___________________________________

_______________________________________________________________________________________________________

Review of Systems (ROS) (check any symptom that you are currently experiencing)

Constitutional Symptoms: [] fever, [] chills, [] weight gain, [] weight loss, [] night sweats, [] fatigue, [] daytime somnolence, [] Failure to thrive

Organ symptoms:

Ophthalmologic: [] blurred vision, [] double vision, [] blindness, [] eye pain, [] itching, [] tearing, [] change in vision, [] field cuts, [] wears glasses

Otolaryngologic: [] hearing loss, [] ringing in ear(s), [] vertigo, [] ear pain, [] ear drainage, [] runny nose, [] nasal congestion, [] nose bleeds, [] post nasal drainage, [] sore throat, [] hoarseness, [] difficulty swallowing, [] snoring, [] headaches, [] dizziness, [] loss of sense of smell, [] throat swelling

Cardiovascular: [] chest pain, [] palpitations, [] shortness of breath on exertion, [] claudication, [] leg swelling, [] heart murmur, [] syncope

Respiratory: [] persistent cough, [] shortness of breath, [] sputum production, [] wheezing

Gastrointestinal: [] nausea, [] vomiting, [] diarrhea, [] abdominal pain, [] heartburn, [] indigestion, [] regurgitation, [] belching, [] vomiting blood, [] rectal bleeding, [] jaundice, [] constipation, [] tarry stools, [] swallowing difficulty

Genitourinary: [] frequency of urination, [] burning on urination, [] vaginal bleeding, [] vaginal drainage, [] urine retention, [] hesitancy/dribbling, [] irregular menstruation

Musculoskeletal: [] muscle or joint pain, [] back pain, [] neck pain, [] stiffness, [] weakness

Integumentary: [] rash, [] skin lesions/ulcers, [] itching, [] changes in nails, [] slow wound healing, [] change in skin color, [] paresthesias

Neurologic: [] numbness of limbs, [] weakness of limbs, [] headache, [] slurred speech, [] tremor, [] facial weakness, [] dizziness, [] loss of consciousness, [] loss of memory, [] seizures, [] unsteady gait

Psychiatric: [] change in mood, [] appetite change, [] behavior change, [] confusion, [] insomnia, [] anxiety, [] depression,

Endocrine: [] heat intolerance, [] cold intolerance, [] hair loss, [] unusual hair growth, [] excess appetite, [] excess hunger, [] excess thirst

Hematologic: [] bleeding, [] easy bruising, [] fatigue, [] swollen lymph glands, [] anemia, [] blood clots

Allergic/Immunologic: [] repetitive sneezing, [] itching in eyes, ears, nose or throat, [] food intolerance, [] congestion

Past Medical, Family, Social History (PFSH):

List your current medications including over-the-counter drugs such as aspirin, Tylenol, ibuprofen, nasal sprays, etc.

Medication and Dose Reason for Taking

_________________________________________ ____________________________________________________

Drug Allergies Type of Reachtion

_________________________________________ ____________________________________________________

Past Medical History:

Have you had or do you currently have any of the following medical conditions? (Check all that apply)

[] High blood pressure [] Irregular heart beat [] Coronary artery disease [] Myocardial infarction

[] Asthma [] Tuberculosis [] Emphysema [] Pneumonia

[] Colitis (IBS) [] Stomach/duodenal ulcer [] Esophageal reflux [] Hiatal hernia

[] Cirrhosis of the liver [] Hepatitis A, B, C [] AIDS [] Bladder problems

[] Kidney problems ]] Enlarged prostate [] Osteoporosis [] Arthritis

[] Skin cancer [] Cancer, site________ [] Anxiety [] Depression

[] Thyroid disorder [] Diabetes, Type I or II [] Infectious mononucleosis [] Lupus

[] Rheumatic fever [] Blood disorder [] Anemia [] Sickle cell anemia

[] Keloids [] Lyme disease [] Epilepsy [] Migraine headaches

[] Glaucoma [] Positive HIV [] Cataracts [] High cholesterol

[] Other_____________ [] Other____________ [] Other___________ [] Other___________

Past Surgical History:

Have you had any of the following operations? Please tell us the year it was performed.

Operation Year Operation Year Operation Year

Tonsils or Adenoids _____ Hernia repair _____ Gall bladder _____

Appendix _____ Hysterectomy _____ Thyroid surgery _____

D & C _____ Coronary bypass _____ Ear surgery _____

Sinus surgery _____ Cataracts _____ Nasal surgery _____

Other _____ Other _____ Other _____

Family History:

Do any of the following diseases tent to run in your family? (Circle all that apply): Heart disease, Cancer, Tuberculosis, High blood pressure, Diabetes, Deafness, Autoimmune Disease, Bleeding disorder, Other__________________________________

If Living If Deceased

Age Current Medical Problems Age at Death Cause of Death

Biologic Father ___ _____________________________ ___ _____________________________________

Biologic Mother ___ _____________________________ ___ _____________________________________

Brothers/Sisters ___ _____________________________ ___ ____________________________________

___ _____________________________ ___ ____________________________________

Social History:

Tobacco:

Have you ever smoked? Y N Number of years you smoked______ Number of packs per day_____

Do you currently smoke? Y N When did you stop smoking?_______

Alcohol:

Do you drink beer, hard liquor, wine (circle all that apply)? Number of years_____. How much do you drink?_____cans/ounces/glasses per day/week (circle which ever applies)

Caffeine:

Please indicate the number of ounces per day_____. Coffee, tea, caffeinated soft drinks (circle any that apply)

Work History:

Please tell us the type of work you have done, where and when you were employed:

________________________________________________________________________________________________________

Pregnancy/Breast feeding/Premedication:

Are you now pregnant? Y N If so, how many weeks?______ Are you currently breast feeding? Y N

Do you require premedication with antibiotics before a dental or surgical procedure? Y N If yes, please tell us the reason_________________________________________________________________________________________________