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All information is strictly confidential FAMILY HISTORY Relation Age Fill in health information about your immediate family. State of Age at Health Death Cause of Death Check if, your blood relatives had any of the following: Disease Relationship to you Father Arthritis, Gout Mother Asthma, Hay Fever Brothers Cancer Chemical Dependency Diabetes Heart Disease, Strokes Sisters High Blood Pressure Kidney Disease Tuberculosis Other HOSPITALIZATIONS/SERIOUS ILLNESS/INJURIES Year Hospital PREGNANCY HISTORY Reason for Hospitalization and Outcome Year of Sex of Birth Birth Complications if any HEALTH HABITS Check which substances you use and describe how much you use. Caffeine Tobacco Have you ever had a blood transfusion? Yes No If yes, please give approximate dates. SOCIAL HISTORY Street Drugs Other To be completed by clinician Occupational Concerns Check if your work exposes you to the following: Stress Hazardous Substances Heavy Lifting Other Your Occupation: To the best of my knowledge, the above information is complete and correct. I understand that it is my responsitility to inform my doctor if I, or my minor child, ever have a change in health. Signature of Patient, Parent, Guardian or Personal Representative Date Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient Reviewed By Date HEALTH HISTORY Confidential Patient Name: Age: What is your reason for visit? Today's Date: Date of last physical examination: Birthdate: SYMPTOMS Check symptoms you currently have. GENERAL GASTROINTESTINAL Chills Appetite poor Depression Bloating Dizziness Bowel changes Fainting Constipation Fever Diarrhea Forgetfulness Excessive hunger Headache Excessive thirst Loss of sleep Gas Loss of weight Hemorrhoids Nervousness Indigestion Numbness Nausea Sweats Rectal bleeding Stomach pain MUSCLE/JOINT/BONE Vomiting Pain, weakness, numbness in: Vomiting blood Arms Hips Back Legs CARDIOVASCULAR Feet Neck Chest pain Hands Shoulders High blood pressure Irregular heart beat GENITO-URINARY Low blood pressure Blood in urine Poor circulation Frequent in urine Rapid heart beat Lack of bladder control Swelling of ankles Painful urination Varicose veins EYE, EAR, NOSE, THROAT Bleeding gums Blurred vision Crossed eyes Difficulty swallowing Double vision Earache Ear discharge Hay fever Hoarseness Loss of hearing Nosebleeds Persistent cough Ringing in ears Sinus problems Vision - Flashes Vision - Halos MEN only Breast Lump Erection difficulties Lump in testicles Penis discharge Sore on penis Other SKIN Bruise easily Hives Itching Change in moles Rash Scars Sore that won't heal WOMEN only Abnormal Pap Smear Bleeding between periods Breast lump Extreme menstrual pain Hot flashes Nipple discharge Painful intercourse Vaginal discharge Other Date of last menstrual period? Date of last Pap Smear? Have you had a mammogram? Are you pregnant? Number of children High Cholesterol HIV Positive Kidney Disease Liver Disease Measles Migraine Headaches Miscarriage Mononucleosis Multiple Sclerosis Mumps Pacemaker Pneumonia Polio Prostate Problem Psychiatric Care Rheumatic Fever Scarlet Fever Stroke Suicide Attempt Thyroid Problems Tonsillitis Tuberculosis Typhoid Fever Ulcers Vaginal Infections Venereal Disease CONDITIONS Check conditions you have or have had in the past AIDS Chemical Dependency Alcoholism Chicken Pox Anemia Diabetes Anorexia Emphysema Appendicitis Epilepsy Arthritis Glaucoma Asthma Goiter Bleeding Disorders Gonorrhea/Chlamydia Breast Lump Gout Bronchitis Heart Disease Bulimia Hepatitis Cancer Hernia Cataracts Herpes MEDICATIONS List medications you are currently taking. ALLERGIES To medications or substances Please indicate if you might be interested in any resources pertaining to these issues: __Academic Pressures __Personal/Emotional Issues __Sexual Assault or Abuse __Alcohol or Other Drug Use __Physical Assault or Abuse __Social Pressures Form 4 Rev. 1 May 2010 All information is strictly confidential Fill in health information about your immediate family. State of Age at Cause of Death Check if, your blood relatives had any of the following: Health Death Disease Relationship to you Arthritis, Gout Asthma, Hay Fever Cancer Chemical Dependency Diabetes Heart Disease, Strokes High Blood Pressure Kidney Disease Tuberculosis Other FAMILY HISTORY Relation Age Father Mother Brothers Sisters HOSPITALIZATIONS/SERIOUS ILLNESS/INJURIES Year Hospital PREGNANCY HISTORY Reason for Hospitalization and Outcome Year of Birth Sex of Birth Complications if any HEALTH HABITS Check which substances Have you ever had a blood transfusion? Yes If yes, please give approximate dates. SOCIAL HISTORY To be completed by clinician No you use and describe how much you use. Caffeine Tobacco Street Drugs Other Occupational Concerns Check if your work exposes you to the following: Stress Hazardous Substances Heavy Lifting Other Your Occupation: To the best of my knowledge, the above information is complete and correct. I understand that it is my responsitility to inform my doctor if I, or my minor child, ever have a change in health. Signature of Patient, Parent, Guardian or Personal Representative Date Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient Reviewed By Date
