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Dr. Howard Adelson, D.O., FAOCO Dr. Todd Adelson, D.O PATIENT MEDICAL HISTORY Patient Name _________________________________________________ Date _____________________ PROBLEM YES/ NO Fever! ! Weight Loss ! ! ! ! ! ❏ Yes ❏ No ! _____________________________ ❏ Yes ❏ No ! _____________________________ ! ! ! ! ! ❏ ❏ ❏ ❏ ❏ Yes Yes Yes Yes Yes ❏ ❏ ❏ ❏ ❏ No ! No ! No ! No ! No ! _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ EARS/NOSE/MOUTH/THROAT Pain! ! ! ! ❏ Mass ! ! ! ! ❏ Discharge! ! ! ❏ Hearing Loss ! ! ! ❏ Loss of smell! ! ! ❏ Other! ! ! ! ❏ Yes Yes Yes Yes Yes Yes ❏ ❏ ❏ ❏ ❏ ❏ No ! No ! No ! No ! No ! No ! _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ CARDIOVASCULAR Chest Pain! ! ! Coronary Artery Disease!! High Blood Pressure! ! Congestive Heart Failure!! Irregular Heartbeat! ! Stroke! ! ! ! Pacemaker! ! ! ❏ ❏ ❏ ❏ ❏ ❏ ❏ Yes Yes Yes Yes Yes Yes Yes ❏ ❏ ❏ ❏ ❏ ❏ ❏ No ! No ! No ! No ! No ! No ! No ! _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ ___________________________ RESPIRATORY Shortness of Breath! ! Chronic Cough/Wheezing! Asthma!! ! ! Emphysema! ! ! Home Use of Oxygen! ! ❏ ❏ ❏ ❏ ❏ Yes Yes Yes Yes Yes ❏ ❏ ❏ ❏ ❏ No ! No ! No ! No ! No ! _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ Social History: ❏ single ❏ married ❏ divorced ❏ widowed ENDOCRINE Diabetes ! ! Thyroid Problems ! ❏ Yes ❏ No ! _____________________________ ❏ Yes ❏ No ! _____________________________ EYE CONCERNS Blurred Vision! ! Double Vision ! ! Pain! ! ! Discharge! ! Other! ! ! ! ! EXPLANATION Do you smoke? ❏ Yes ❏ No # of packs/day ________ # of years ____________ Do you use alcohol? ❏ None ❏ Socially ❏ 2-3 times/week ❏ with dinner Do you exercise? ❏ None ❏ occassionally ❏ weekly ❏ daily Do you drive? ❏ Yes ❏ No Occupation: 42000 Six Mile Road - Suite 200 - Northville, MI 48167 | 248-449-9292 30300 Hoover, Suite 200 - Warren, MI 48093 | 586-573-3937 PATIENT MEDICAL HISTORY (page 2) GASTROINTESTINAL Bowel Changes !! Crohns Disease!! Hiatal Hernia! ! Stomach Pain! ! Ulcers ! ! ! Other! ! ! ❏ ❏ ❏ ❏ ❏ ❏ Yes Yes Yes Yes Yes Yes ❏ ❏ ❏ ❏ ❏ ❏ No ! No ! No ! No ! No ! No ! _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ HEMATOLOGIC/LYMPHATIC Anemia!! ! ! ❏ Hepatitis ! ! ! ❏ Hemophilia! ! ! ❏ HIV +! ! ! ! ❏ Rheumatic Fever ! ! ❏ Tuberculosis ! ! ! ❏ Yes Yes Yes Yes Yes Yes ❏ ❏ ❏ ❏ ❏ ❏ No ! No ! No ! No ! No ! No ! _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ MUSCULOSKELETAL Weakness/Numbness ! Joint Pain/Muscle Pain ! Artificial Joint ! ! Arthritis ! ! SKIN/BREAST Masses ! Tumors ! Rash ! ! Bruising ! Herpes !! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ❏ ❏ ❏ ❏ ! ! ! ! ! NEUROLOGIC Seizures ! ! ! Epilepsy ! ! ! Parkinson’s Disease ! ! Dizzy Spells ! ! ! Sever Headaches/Migraines ! Yes Yes Yes Yes PLEASE DO NOT WRITE BELOW THIS LINE ROS & Social History Updates _____________________________ _____________________________ _____________________________ _____________________________ Yes Yes Yes Yes Yes ❏ ❏ ❏ ❏ ❏ No ! No ! No ! No ! No ! _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ ❏ ❏ ❏ ❏ ❏ Yes Yes Yes Yes Yes ❏ ❏ ❏ ❏ ❏ No ! No ! No ! No ! No ! _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ Year ! Initials ________ _______ ________ _______ ________ _______ ________ _______ FOR OFFICE USE ONLY Reviewed by: PHYSICIAN SIGNATURE: __________________________ ❏ Yes ❏ Yes ❏ Yes ❏ Yes CANCER Treatment ! Chemotherapy Radiation ! Surgery ! ❏ ❏ ❏ ❏ ! ! ! ! No ! No ! No ! No ! ❏ ❏ ❏ ❏ ❏ RENAL Kidney Disease !! ! Dialysis ! ! ! Transplant ! ! ! Frequent Urinary Tract Infection ! !! ! ! ❏ ❏ ❏ ❏ FOR OFFICE USE ONLY Yes Yes Yes Yes ❏ No ! ❏ No ! ❏ No ! ❏ No ! _____________________________ _____________________________ _____________________________ _____________________________ No ! No ! No ! No ! _____________________________ _____________________________ _____________________________ _____________________________ ❏ ❏ ❏ ❏ 42000 Six Mile Road - Suite 200 - Northville, MI 48167 | 248-449-9292 30300 Hoover, Suite 200 - Warren, MI 48093 | 586-573-3937 Date ____________
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