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LOFTS MEDICAL ASSOCIATES HEALTH HISTORY PATIENT INFORMATION Patient Name: Last _______________________________ First _______________________________ Sex M F Date of Birth ______/______/________ Your answers on this form will help your clinician understand your medical concerns and conditions better. If you are uncomfortable with any question, do not answer it. Best estimates are fine if you cannot remember specific details. Thank you! MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs: Medication Dose Times per day Medication Dose Times per day ALLERGIES or REACTIONS TO MEDICINES/FOODS/OTHER AGENTS: Medication Reaction or Side Effect PERSONAL MEDICAL HISTORY Please indicate whether you have had any of the following medical problems (with approximate date of illness or diagnosis): ___ Congenital Heart disease: specify type _____________ ___ Myocardial Infarction (Heart attack) ___ Hypertension (High blood pressure) ___ Diabetes ___ High cholesterol ___ Stroke ___ Coagulation (bleeding/clotting) disorder ___ Cancer (Malignancy) specify type _____________ ___ Depression/suicide attempt ___ Alcoholism ___ Thyroid problem specify type _____________ ___ Other problems ___ When was your last Tetanus shot? SURGICAL & HOSPITALIZATION HISTORY (Please list all prior operations and dates): Operation Date SOCIAL HISTORY Tobacco Use: Cigarettes ___ Quit: Date__________ ___ Never ___ Current: Smoker: packs/day____ # of yrs ________ Are you interested in quitting? ___ No ___ Yes Hospitalization Date Caffeine Use Do you drink liquids containing caffeine? ___ No ___ Yes Alcohol Use Do you drink alcohol? ___ No ___ Yes: # drinks/week_____ EXERCISE: Do you exercise regularly? ___ No ___ Yes FAMILY HISTORY Please indicate with a check (√) family members who have had any of the following conditions: Medical Condition Mom Dad Sist. Bro. GRParent other Anemia Glaucoma Medical Condition Mom Dad Sist. Bro. GR-Parent other Stroke Breast Cancer Colon Cancer Ovary Cancer Prostate Cancer Lupus Asthma Heart Attack High Blood Pressure High cholesterol Kidney diseases Depression Alcoholism Thyroid disorders Epilepsy Diabetes, Type 1 Diabetes, Type 2 Bleeding problem IMMUNIZATIONS Please list your most recent immunizations. Please include your best estimate of the month and year of each immunization. DATE IMMUNIZATION Hepatitis A Hepatitis B Tetanus (Td) Tetanus (Tdap) DATE IMMUNIZATION Measles Mumps Rubella MMR DATE IMMUNIZATION Pneumovax (Pneumonia) Varicella shot (Shingles) Other: REVIEW OF SYSTEMS Please check (√) any current problems you have on the list below. Constitutional ___Fevers/chills/sweats ___Fatigue/weakness ___Excessive thirst or urination Eyes ___Change in vision Ears/Nose/Throat/Mouth ___Difficult hearing/ringing in ears ___Problems with teeth/gums ___Hay fever/allergies Cardiovascular ___Chest pain/discomfort ___Leg pain with exercise ___Palpitations Skin ___ Rash or mole change Gastrointestinal ___Abdominal pain ___Blood in bowel movement ___Nausea/vomiting/diarrhea Psychiatric ___Anxiety/stress ___Problems with sleep ___Depression Chest (breast) ___Breast lump/discharge Respiratory ___Cough/wheeze ___Difficulty breathing Musculo-skeletal ___Muscle/joint pain Blood/Lymphatic ___Unexplained lumps ___Easy bruising/bleeding Genitourinary ___Nighttime urination ___Leaking urine ___Unusual vaginal bleeding ___Discharge: penis or vagina ___Sexual function problems Other (please specify) ____ Neurological ___Headaches ___Dizziness/light-headedness ___Numbness ___Memory loss ___Loss of coordination
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