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Initials DEMOGRAPHICS NAME: DATE DOB: REASON FOR VISIT (CHIEF COMPLAINT) PAST MEDICAL HISTORY N/A Please indicate below your history of diseases with an “X” in the appropriate box. Check off “C” if it is a current disease and “P” if it is a past disease. If you have never encountered a problem with a particular disease, please leave blank. C P C P C P 530.81 Acid Reflux (GERD) [K21.9] 477 Allergies/Hay Fever 285.9 Anemia 300.0 Anxiety [F41.9] 493.90 Asthma 427.31 Atrial fibrillation 296.80 Bipolar Disorder [F31.9] 490 Bronchitis 946 Burns 199 Cancer (site) 425 Cardiomyopathy 366.9 Cataracts 272.0 Cholesterol elevation 008.45 C difficile enterocolitis 428.0 Congestive heart failure 491.21* COPD [J44.1] 414.0 Coronary athersclerosis 555* Crohn’s Disease 453.4 Deep vein thrombosis 290 Dementia 311 Depression 250 Diabetes 562 Diverticulosis/itis 304 Drug Abuse 380.1 Ear Infections (recurrent) 492 Emphysema 692 Eczema 424.9 Endocarditis (heart infection) 345 Epilepsy (seizure) 302.7* Erectile Dysfunction 729.1* Fibromyalgia 054.1 Genital Herpes 365 Glaucoma 098* Gonorrhea 274 Gout 784.0 Headache 389 Hearing loss 410 Heart Attack 785.2* Heart Murmur 787.1 Heartburn 455 Hemorrhoids 070 Hepatitis, viral 070.1 Hepatitis A 070.3 Hepatitis B 070.54 Hepatitis C 722* Herniated Disc(s) 054 Herpes Simplex 053.9 Herpes Zoster (shingles) 042 HIV/AIDS [B20] 401.9 Hypertension 242* Hyperthyroidism 244.9 Hypothyroidism 564.1 Irritable bowel syndrome 592 Kidney stones 585 Kidney disease, chronic 208 Leukemia 202* Lymphoma 695.4 Lupus (SLE) 322.9 Meningitis 346.9 Migraine [G43.909] 340 Multiple Sclerosis 278.00 Obesity 715.0 Osteoarthritis 730.28 Osteomyelitis (site) 733.0 Osteoporosis 332 Parkinson’s disease [G20] 533 Peptic ulcers 443.9 Peripheral vascular disease 486 Pneumonia 600 Prostate enlargement 601.9 Prostatitis 696.1 Psoriasis 585.9 Renal disease 586 Renal failure 390 Rheumatic fever 714.0 Rheumatoid arthritis 724.3 Sciatica 461 Sinusitis, acute 473 Sinusitis, chronic 556* Ulcerative colitis HOSPTIALIZATIONS/SURGERIES DATE(S) REASON Stephen A. Renae, M.D. FACP Infectious Diseases/Internal Medicine Telephone: (954) 776-9992 DURATION N/A Types (M=Medical, S=Surgical or P= Psychiatric) TYPE 4800 NE 20th Terrace, Suite 115 Fort Lauderdale, FL 33308 Facsimile: (954) 776-9993 Initials MAJOR INJURIES OR ACCIDENTS N/A Please list MEDICATIONS N/A List all prescription and non-prescription medications, vitamins, home remedies, birth control pills and herbal preparations. MEDICATION DOSE MEDICATION ALLERGIES MEDICATION NON MEDICATION ALLERGIES ALLERGEN (EX: FOOD, TAPE, LATEX) Stephen A. Renae, M.D. FACP Infectious Diseases/Internal Medicine Telephone: (954) 776-9992 N/A LOCATION AND REACTION (SKIN, LOCAL, ABDOMINAL, ANAPHYLACTIC) LOCATION AND REACTION (SKIN, LOCAL ABDOMINAL, ANAPHYLACTIC) VERY MILD, MILD, MODERATE, SEVERE N/A VERY MILD, MILD, MODERATE, SEVERE 4800 NE 20th Terrace, Suite 115 Fort Lauderdale, FL 33308 Facsimile: (954) 776-9993 Initials FAMILY HISTORY Have any of your blood relatives had any of the following diseases? Please document which family member(s) in the space provided. YES NO DISEASE RELATIVE(S) EX: MOTHER, FATHER, AUNT, UNCLE, COUSIN Cancer Diabetes mellitus Heart disease High blood pressure High cholesterol Kidney disease Osteoporosis Stroke Thyroid disease Tuberculosis Other: Other: Other SOCIAL HISTORY In what type of dwelling do you reside? House Apartment Townhome Villa Mobile Home Other specify: Does anyone live at home with you? If so, who? Do you have any hobbies? If so, briefly describe. Do you have any pets? If so, please list them Different culinary habits? Ex: raw fish, raw steak, etc. Is spirituality important to you? No Yes Would you like to discuss spiritual matters with your physician? No Yes IMMUNIZATIONS / TRAVEL HISTORY N/A Have you ever had any of the following immunizations; if so when? Hepatitis A Hepatitis B Influenza (Flu Shot) Measles Rubella Tetanus Stephen A. Renae, M.D. FACP Infectious Diseases/Internal Medicine Telephone: (954) 776-9992 4800 NE 20th Terrace, Suite 115 Fort Lauderdale, FL 33308 Facsimile: (954) 776-9993 Initials IMMUNIZATIONS / TRAVEL HISTORY (CONTD) Pneumonia (Pneumovax) N/A Other Varicella (Chicken pox) or illness BCG (Tuberculosis vaccine) PPD (Tuberculosis test) Have you ever-been diagnosed with tuberculosis? If yes, when were you treated? How long were you treated for? Previous cities and states visited within the United States: Have you traveled outside of the United States? If so, where and when did you travel? RISK ASSESSMENT Tobacco Use: Never used. Current use: Quit; when __________ _____ How long used? _____________________ Cigarettes________ packs per day. Pipe Chewing tobacco How long have you been using?____________months/years. Are you interested in information about quitting? Yes No. Alcohol use: Do you drink alcohol (beer, wine or spirits)? No Is your alcohol use a concern to you or others? Are you interested in trying to quit? Yes Yes; Number of drinks per week:___________ Yes No . No. Drug Use: Do you use recreational drugs? No Yes; How long have you been using?_________________ Which substances have you been using? Please check below: Marijuana Cocaine Crack cocaine Heroin Do you share needles? Yes No N/A. Are you interested in trying to quit? Stephen A. Renae, M.D. FACP Infectious Diseases/Internal Medicine Telephone: (954) 776-9992 Methamphetamines Opioids Others_______________________________ Yes No. 4800 NE 20th Terrace, Suite 115 Fort Lauderdale, FL 33308 Facsimile: (954) 776-9993 Initials RISK ASSESSMENT (CONTD.) Piercings/Tattoos: Do you have piercings or tattoos? If so, where and when did you get them done?_____________ Diet: How do you rate your diet? Good Are you satisfied with your weight? Fair Poor. Height: Yes __ Weight___________lbs. No. If no, what are you doing about it? Advance Directives: Do you have a living will? Yes No. Are you interested in information regarding living wills? Yes No. Caffeine Intake: No Yes Coffee/Tea:_______ cups/day Soda: ______cans,glasses /day Chocolate: _______ oz. /day Sexual Activity: Are you sexually active: No Yes Current sex partner(s) is/are: Male Do you have multiple partners? Do you practice safer sex? No Not currently Female No Both Yes. Are you interested in changing this behavior? Yes No Yes. If yes, what methods do you use? Have you have ever had sexually transmitted diseases? If so when? Gonorrhea Syphilis Chlamydia Have you ever been tested for HIV? Was it negative or positive? HPV No Negative Hepatitis Trichomonas Others: Yes If so when was your last test? Positive REVIEW OF SYSTEMS Review of Systems (Check symptoms you are experiencing currently) General Dry mouth Weight loss or gain Sore throat Fatigue Fever or chills Weakness Hoarseness Thrush Non-healing sores Neck Lumps Swollen glands Trouble sleeping Skin Rashes Stephen A. Renae, M.D. FACP Infectious Diseases/Internal Medicine Telephone: (954) 776-9992 Yellow eyes or skin Urinary Frequency Urgency Burning or pain Blood in urine Incontinence Change in urinary strength 4800 NE 20th Terrace, Suite 115 Fort Lauderdale, FL 33308 Facsimile: (954) 776-9993 Initials REVIEW OF SYSTEMS (CONTD.) Skin Lumps Skin Itching Skin Dryness Skin Color changes Neck Pain Neck Stiffness Breasts Lumps Hair and nail changes Head Pain Discharge Self-exams Breast-feeding Respiratory Cough Headache Head injury Neck Pain Ears Decreased hearing Ringing in ears Earache Drainage Eyes Vision Loss/Changes Glasses or contacts Pain Redness Blurry or double vision Flashing lights Specks Nose Stuffiness Discharge Itching Hay fever Nosebleeds Sinus pain Throat Bleeding Dentures Sore tongue Sputum Coughing up blood Shortness of breath Wheezing Painful breathing Cardiovascular Chest pain or discomfort Tightness Palpitations Shortness of breath with activity Difficulty breathing lying down Swelling Sudden awakening from sleep with shortness of breath Gastrointestinal Swallowing difficulties Heartburn Change in appetite Nausea Change in bowel habits Rectal bleeding Constipation Vascular Leg cramping Calf pain with walking Musculoskeletal Muscle or joint pain Stiffness Back pain Redness of joints Swelling of joints Trauma Neurologic Dizziness Fainting Seizures Weakness Numbness Tingling Tremor Hematologic Ease of bleeding Ease of bruising Endocrine Change in appetite Head or cold intolerance Sweating Frequent urination Thirst Psychiatric Nervousness Stress Depression Memory loss Diarrhea SIGNATURE By signing below I certify the information above is accuracte truthful and correct to the best of my knowledge. Signee: Patient Power of Attorney Family member Other Signature Date . Stephen A. Renae, M.D. FACP Infectious Diseases/Internal Medicine Telephone: (954) 776-9992 4800 NE 20th Terrace, Suite 115 Fort Lauderdale, FL 33308 Facsimile: (954) 776-9993
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