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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: Pg 1 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 Pg 2 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: Pg 3 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 Pg 4