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INOVA Mesquite
Name
Date of Birth
Sex
Date
Who referred you to our office?
Other Physicians you see:
Occupation:
Marital Status:
Place of Employment
Single
Married
Separated
Divorced
Widowed
Number of Children
REASON FOR TODAY’S VISIT:
Have you ever been treated for this problem before?
Yes
No
If yes, please give details:
Do you consider this a work-related injury?
If yes, date of injury:
Yes
No
Please describe your injury:
ALLERGIES List all known allergies and reactions:
MEDICAL HISTORY (Check all that apply)
YES
Hypertension
(High Blood Pressure)
Stroke
Seizures
Migraines
Anemia
Lung cancer
Breast cancer
Colon cancer
Skin cancer
Other cancer:
Hyperthyroid
Hypothyroid
Diabetes
Stomach or Peptic Ulcer
Kidney Disease
Sleep Apnea
Liver Disease
Hepatitis
AIDS/HIV
Sexually Transmitted
Disease
Rheumatic Fever
Cataract
Glaucoma
Asthma
Date
YES
Date
YES
TB (Tuberculosis)
Other Arthritis
Pneumonia
Emphysema (COPD)
Or Chronic Bronchitis
Heart Abnormalities
Congestive Heart Failure
Myocardial Infarction
(Heart Attack)
Mitral Valve Disease
High Cholesterol
Coronary Artery Disease
Gout
Date
Osteoporosis/Osteopenia
Skin disease
Phlebitis/blood clots
Anemia
Bleeding disorder
Depression
Anxiety
Psychiatric
Chicken Pox
Heart Murmur
Heart Valve Disease
Heart Palpitations or
Arrhythmias
Pulmonary fibrosis
Any other lung disease
not
Mentioned
Hiatal hernia/GERD
Gallstones
Pancreatitis
Colitis (not spastic colon)
Spastic colon or irritable
Bowel
Kidney stones
Kidney infections
Rheumatoid arthritis
Osteoarthritis
Measles
Mumps
Infectious Mono
Allergies/Hay fever
Hives or Eczema
Blood Transfusion
Bladder Infections
Hemorrhoids
Hernia
Back Problems
Other:
Other:
Other:
Other:
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INOVA Mesquite
MEN ONLY:
YES
Date
YES
Prostate Problems
WOMEN ONLY:
Date
Prostate Cancer
YES
Date
YES
Uterine Cancer
Abnormal Pap Smear
Date
Cervical Cancer
Pregnancies:
Deliveries:
Method of Birth Control if Applicable
YES
Date
YES
Date
Cancer of the Testicles
Ovarian Cancer
Miscarriages:
Date of Last Menstrual Period
Abortions:
Could you be pregnant?
Yes
No
Other Medical History:
FAMILY HISTORY
Please indicate in the spaces below any family members with a history of diabetes, heart disease, cancer, emphysema,
kidney disease, asthma, bleeding tendencies, anemia, epilepsy, glaucoma, high blood pressure, gout, arthritis, ulcer,
stroke, nervous breakdown, gall bladder disease.
Family Member
Father
Paternal Grandfather
Paternal Grandmother
Mother
Maternal Grandfather
Maternal Grandmother
Brothers
(How many in all?
Sisters
(How many in all?
Sons
(How many in all?
Daughters
(How many in all?
Other family members
Age if Living
Health Problems
Age at Time
of Death
Cause
)
)
)
)
SURGICAL HISTORY
Check all that apply:
YES
Cholecystectomy (Gallbladder)
Appendectomy
Tonsillectomy
Hysterectomy
Mastectomy
Hip Replacement
Date
YES
Date
Knee Replacement
Hernia Repair
Pacemaker
Other:
Other:
Other:
Please list as best you can, any times that you have been hospitalized:
Example: 1985 Presbyterian Hospital of Dallas Pneumonia
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INOVA Mesquite
SOCIAL HISTORY
Check all that apply:
Your Personal habits: Do you?
Smoke
Drink Alcohol
Use recreational/Intravenous street drugs
YES
NO
Date Quit
If Yes, how much/how often?
MEDICATIONS
List all current medications, prescription and nonprescription (EXAMPLE: ASPRIN, HERBALS, VITAMINS):
Medication
Dose
Frequency
Start Date
HEALTH MANAGEMENT:
Please indicate when you last had each of the following exams and if the results were normal/abnormal:
Date Normal Abnormal
Date Normal
Dental
Ophthalmology
Stress Test
Colonoscopy (over age 50)
Stool Test for Blood
Chest X-ray
Tuberculosis Skin Test (PPD)
Pneumonia Shot
Hepatitis A & B
Gardisil Shot(s) (female)
Do you exercise on a regular basis?
If so, how much and how often?
Do you drink caffeine? D Yes
If so, how much and how often?
Abnormal
Bone Density Test/DEXA
Mammogram (female)
Pelvic/Pap Smear (female)
Breast Exam (female)
PSA Exam (male)
Rectal/Prostate Exam (male)
Tetanus Shot
Flu Shot
Shingles Shot
Other:
D Yes D No
D No
Do you always use your seatbelt when you drive?
D Yes D
No
OTHER MEDICAL ISSUES:
Please list any other issues that you wish to discuss with the physician:
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INOVA Mesquite
SYSTEM REVIEW
Instructions: Please circle any of the following that apply to your RECENT health.
Constitution
Fever
Chills
Weight Loss
Malaise/Fatigue
Diaphoresis (sweating)
Weakness
Skin
Rash
Itching
HENT
Headaches
Hearing Loss
Tinnitus (ringing in ears)
Ear Pain
Ear Discharge
Nosebleeds
Congestion
Stridor
Sore Throat
Eyes
Blurred Vision
Double Vision
Photophobia (light
sensitivity)
Eye Pain
Eye Discharge
Eye Redness
Cardiovascular
Chest Pain
Palpitations (fast heart beat)
Orthopnea (shortness of breath when laying flat)
Claudication (calf pain w/walking)
Leg swelling
PND (walking up w/shortness of breath)
Cough
Hemoptysis (coughing up blood)
Sputum production
Shortness of breath
Wheezing
Gastrointestinal
Heart Burn
Nausea
Vomiting
Abdominal Pain
Diarrhea
Constipation
Blood in Stool
Melena (black sticky stool)
Genitourinary
Dysuria (pain w/urination)
Urgency
Musculoskeletal
Myalgias (Muscle Pains)
Neck Pain
Back Pain
Joint Pain
Falls
Endo/Heme/Allergy
Easy bruise/bleed
Environmental Allergies
Polydipsia (excessive thirst)
Neurologic
Dizziness
Tingling
Termor
Sensory Change
Speech Change
Focal Weakness
Seizures
LOC (passing out)
Psychiatric
Depression
Suicidal Ideas
Substance Abuse
Hallucinations
Frequency
Hematuria (Blood in Urine)
Flank Pain
Nervous/Anxious
Insomnia
Memory Loss
I have read all of the above and I agree that all UNMARKED responses are NOT symptoms
that apply to my recent health.
Please Sign:
Date:
050913 Rev
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