Download PAST MEDICAL/FAMILY/SOCIAL HISTORY MEDICAL

PAST MEDICAL/FAMILY/SOCIAL HISTORY
MEDICAL CONDITIONS [ ] Diabetes
[ ]Cancer [ ]Asthmas
[ ]Chronic Lung Disease
[ ]high blood pressure
[ ]Tuberculosis [ ] OTHER ____________
PREVIOUS SURGERIES [ ]Heart [ ]Tonsils [ ]Appendix [ ]Gall Bladder [ ]Hysterectomy
[ ] OTHER _______________________
FAMILY HISTORY:
Any chronic or hereditary illness?
Please list all prescription, medications, herbs, vitamins, and over the counter medications
ALLERGIES (LIST):
MARITAL STATUS _____________
OCCUPATION _________________
LEVEL OF EDUCATION: # OF YEARS COMPLETED _______________
ALCOHOL USE? [ ] NO [ ] YES
DRUG USE? [ ] NO [ ] YES
SMOKE CIGARETTES? [ ] NO [ ] YES
pack(s) per day=_____________
IMMUNIZATIONS: Tetanus booster in last 5 years? [ ] NO [ ] YES
Last flu shot ___________________ Date of last pneumovax________________
REVIEW OF SYSTEMS
PLEASE CHECK QUESTIONS: [√] No Problem [√] Problems you are having now [√]Other & explain below
GENERAL/CONSTITUTIONAL [ ] no problem
[ ] fever/chills
[ ]poor appetite
[ ]tired
[ ]other
EYES
[ ] no problem
[ ] discharge
[ ]blurred vision
[ ]other
EARS
[ ] no problem
[ ]pain
[ ]decreased hearing [ ]itching
[ ]other
NOSE
[ ] no problem
[ ]pain
[ ]drainage hearing [ ]congestion
[ ]other
THROAT
[ ] no problem
[ ]pain
[ ]hurts to swallow
[ ]swelling
[ ]other
HEART & BLOOD VESSELS [ ] no problem
[ ]chest pain
[ ]bad circulation
[ ]varicose vein [ ]other
RESPIRATORY
[ ] no problem
[ ]cough
[ ]difficulty breathing [ ]wheezing
[ ]other
ESOPHAGUS
[ ] no problem
[ ]painful swelling [ ]difficulty swallowing
[ ]other
STOMACH
[ ] no problem
[ ]heartburn
[ ]nausea
[ ]vomiting
[ ]other
INTESTINES, COLON
[ ] no problem
[ ]pain
[ ]constipation [ ]diarrhea [ ]bleeding [ ]other
PELVIC
[ ] no problem
[ ]problems with period [ ]vaginal discharge [ ]sex pain [ ]other
URINATION
[ ] no problem
[ ]painful
[ ]blood
[ ]frequent
[ ]other
[ ] hard to get started [ ]loose it with cough or sneeze
[ ]weak stream
MUSCLES & BONES
[ ] no problem
[ ]arthritis [ ]neck pain [ ]arm problem [ ]leg problem [ ] other
NEUROLOGIC
[ ] no problem
[ ]headache
[ ]weak
[ ]memory loss [ ]numb [ ]other
SKIN
[ ] no problem
[ ]rash
[ ]color change [ ]abnormal sweating [ ]other
BREASTS
[ ] no problem
[ ]pain
[ ]lumps
[ ]other
PSYCHIATRIC
[ ] no problem
[ ]depression
[ ]anxiety [ ]hallucinations [ ]anger
[ ]other
ENDOCRINE
[ ] no problem
[ ]abnormal thirst [ ]cold all the time[ ]hot all of the time [ ]other
[ ] abnormal weight loss/gain
[ ]abnormal hair loss or gain
BLOOD
[ ] no problem
[ ]anemia
[ ]easy bruising
[ ]other
LYMPH NODES
[ ] no problem
[ ]painful
[ ]swollen
[ ]other
ALLERGIC, IMMUNOLOGIC [ ] no problem
[ ]hives
[ ]food allergy
[ ]hay fever
[ ]other
[ ]low resistance to infection
EXPLAIN OTHER [ ] Boxes checked and list any other problems you are having
NAME:____________________________________________ DATE OF BIRTH________________________
DATE:_____________________________________________ REVIEWED BY:_________________________