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CROUCH CLINIC PATIENT MEDICAL HISTORY and REVIEW OF SYSTEMS
Name: ___________________________________Date of Birth: __________ Sex: M F Today’s Date: ___________
Primary Care Physician:
Physician’s Phone: ______________________
Physician Address: ___________________________________________
DRUG ALLERGIES
General
Head/Ears/Nose/Throat
Pulmonary
List all DRUG Allergies:
______________________
______________________
______________________
______________________
______________________
______________________
Unplanned Weight
Change
Fevers
Chills/Sweats
Loss of Energy
Fatigue
Cardiac
Glaucoma
Glasses/Contacts
Cataract/Visual Problems
Hearing Problems
Sore Throat
Sinus Infection
Seasonal Allergies
Gastrointestinal
Chest Pain with Exertion
Chest Pressure
Heart Failure
Palpitations/Irregular Beat
Murmur/Rheumatic Fever
Coronary Artery Disease
Heart Attack
Hematological
Abdominal Pain
Trouble Swallowing
Nausea
Vomiting
Black/Tarry Stool
Yellow Jaundice
Liver Disease
Neurological
Abnormal Bleeding
Easy Bruising
Blood Clots in Legs/Lungs
HIV/AIDS
Nose Bleeds
Hepatitis B
Hepatitis C
Diarrhea
Constipation
Bright Red Blood in Stool
Hemorrhoids
Stomach Ulcers
Heartburn or Acid Reflux
Gallbladder Disease
Musculoskeletal
Neurologic Disease
Chronic Headaches
Migraines
Dizziness
Passing Out
Seizure/Epilepsy
Stroke
Joint Pain
Swelling Extremities
Back Pain
Leg Pain
Leg Ulcers
Varicose Veins
Leg Cramps
Asthma
Cough
Wheezing
Shortness of Breath
Positive TB Test
Emphysema/COPD
Insomnia
Daytime Sleepiness
Snoring
Sleep Apnea
Never Feel Rested
Use of CPAP
Previous Sleep Study
Genitourinary
Metabolic
Blood in Urine
Hesitancy
Kidney Stones
Frequent Urination
Pain on Urination
Prostate Problems
High Blood Pressure
Diabetes
High Cholesterol
Thyroid Problems
Anemia
Other____________
Other____________
Freq.Urinary Infection
Psychological
Gynecological
Depression
Anxiety
Stress
Emotional Eating
Ever received
psychiatric treatment or
counseling
FIRST DATE OF LAST
PERIOD__________
Breast Pain/Lumps
Breast Discharge
Menopause
Hysterectomy
Irregular Cycle
Weight History: Current weight______
Weight one year ago______ Goal Weight______ Usual Healthy weight______
Highest NON-PREGNANT weight______ How tall are you? ______ feet ______ inches
reason you want to lose weight? _____________________________________________________________________
Weight at age 20______
What is the main
What is the main cause of your weight gain? _____________________________________________________________
LIST ALL SURGERIES/DATES
CURRENT MEDICATIONS/DOSAGE
______________________
______________________
______________________
______________________
______________________
______________________________
______________________________
______________________________
______________________________
______________________________
PREVIOUS WEIGHT LOSS
ATTEMPTS,MEDICATIONS,DIETS
________________________
________________________
________________________
________________________
ADDITIONAL MEDICAL HISTORY
__________________________
__________________________
__________________________
__________________________
__________________________
Have you ever had any type of eating disorder? Y/N Which disorder?(Please circle) anorexia/bulimia/laxative abuse
Do you exercise? _______ What Kind? ___________________________________ How Much? ____________________
Do you eat breakfast?__ lunch?__ dinner?__ at night? __ when stressed? ___
Do you: SMOKE? Y/N____packs/day x ___years; use CAFFEINE? Y/N_____drinks/day;
Do you: Use STREET DRUGS? Y/N _________________
drink ALCOHOL? Y/N_____drinks/week
Are you: ___ married ___single ___divorced ___separated. Number of children_____ Ages____________________
Family Medical History: (Please circle) Has any blood relative ever had Diabetes, Cancer, Heart Disease, Kidney Disease,
Liver Disease, Stroke, High Blood Pressure, Thyroid Disease, Glaucoma, Arthritis, Obesity or Psychiatric Disorder?
Age
Health
Medical Problems
Cause of Death
Overweight?
Father: ____________________________________________________________________________________________
Mother: ___________________________________________________________________________________________
Brothers: __________________________________________________________________________________________
Sisters: ___________________________________________________________________________________________
Other Relatives: ____________________________________________________________________________________
Patient Signature_____________________________________ Physician/PA Signature___________________________
Your signature indicates the above information is complete and true.
Physician/PA will sign after reviewing with patient.
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