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Download Medical History (check all that apply) Past Surgical History Health
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Reason for Today's Visit: __________________________________________________________________ Medical History (check all that apply) Heart & Vessels Blocked Vessels Clotting disorder Heart Attack Heart Rhythm Problems High Blood Pressure High Cholesterol History of Blood Clot Stroke Endocrine Diabetes Gastrointestinal Bowel Disease Thyroid Disorder Heartburn Irritable Bowel Liver Disease Ulcers Immune System Allergies Infectious Disease Hepatitis A, B, or C Musculoskeletal Arthritis Cancer Breast Neurologic / Psychiatric Chemical Dependency Depression/Anxiety Epilepsy Mental Illness Migraines Multiple Sclerosis Herpes (Cold Sores) HIV/AIDS Fibromyalgia Cervical Colon Lungs Asthma COPD Reproductive Abnl Pap Smears Breast Lumps Kidney / Urinary Kidney Infections Kidney Disease Lung Emphysema Prostate Skin Tuberculosis Pneumonia Prostate Problem Sexual Diseases Kidney Stones Incontinence Other Medical Conditions Past Surgical History Procedure Date Procedure Date Procedure Date Other Surgical History Health Habits Tobacco Use Current Former No History Alcohol Use Current Former No History Drug use Current Former No History Caffeine Use 1-2 daily 3-5 daily > 5 daily Reason for Today's Visit: __________________________________________________________________ Name Dose Frequency Taken Medications / Supplements 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Medication Allergies / Adverse Reactions Name and Reaction Type 1. 2. 3. 4. Family History Diabetes Mother Father Brother Sister Grandparents Heart Disease Mother Father Brother Sister Grandparents High Blood Pressure Mother Father Brother Sister Grandparents High Cholesterol Mother Father Brother Sister Grandparents Cancer include location Mother Father Brother Sister Grandparents Other Family History Reason for Today's Visit: __________________________________________________________________ Current Symptoms (check all that apply) General Head, Eyes, Ears, Nose, Throat Fever/chills Headache Fatigue/malaise Weight Gain Night Sweats Excessive Thirst Weight Loss Visual Changes Eye Pain Nasal Congestion Nasal Drainage Sinus Pain Mouth/Dental Pain Sore Throat Ear Pain Hearing Changes Enlarged Lymph Nodes Cardiovascular Chest Pain Palpitations Shortness of Breath Difficulty Breathing Lying Down Swelling Fainting Leg Pain with Walking Respiratory Cough Gastrointestinal Loss of Appetite Difficulty Swallowing Abdominal Pain Heartburn Hoarse Voice Nausea/Vomiting Vomiting Blood Indigestion Black Stools Constipation Diarrhea Hemorrhoids Blood in Stool Yellowing of Skin Genitourinary Musculoskeletal Shortness of Breath Wheezing Coughing Blood Difficulty Urinating Frequent Urination Genital Sores Blood in Urine Erection Difficulty (male) Decreased Libido Menstrual Problems (female) Itching/Odor/Discharge Joint Pain Joint Swelling Back Pain Muscle Weakness Neurologic / Psychiatric Numbness/Tingling Tremor Incoordination Dizziness Memory Loss Seizures Depression / Anxiety Insomnia Suicidal Thoughs Muscle Pain
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