PATIENT MEDICAL HISTORY                                                                                 Date:____________

NAME_______________________________________________Date of Birth______________ Age___

Concerns/Questions regarding your health that you would like addressed today:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Past Medical Problems including surgeries and hospitalization:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICATIONS:                1. _________________   3.______________     5.________________
(Prescription & over the counter)
                                          2. _________________  4. ________________ 6. ________________

Drug Allergies:      _____________________________________________________________________________________

Immunizations:  (YR)  Tetanus Booster  __________      Measles/Mumps/Rubella   __________
                                      Influenza             __________      Pneumovax                        __________
                                      Hepatitis B          __________      Chicken Pox/Varicella       __________

Please list all the physicians you have seen in the past year:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FAMILY HISTORY:  (List medical problems - including hypertension, diabetes, heart disease, cancer)

                                            Age            Medical Problems
Mother_________________________________________________________________________________

Father_________________________________________________________________________________

Brother (s)______________________________________________________________________________

Sister (s)_______________________________________________________________________________

Children _______________________________________________________________________________

Grandparents____________________________________________________________________________


SOCIAL HISTORY:

Tobacco:________________packs/day ______ years.    Previous quit  ( Y / N)

Alcohol:  Drinks per day:_______ ;      per week:_______;      per month_______; Please specify:_________

Drugs (list) _________________________________________________________________________

Do you exercise regularly?  (frequency, form)__________________________________________________

Do you follow a special diet?   ___________________________________________________

Do you regularly wear a seatbelt?      __________ How much caffeine do you drink per day?_____________

Any history of high risk sexual behavior? ___________________________________________________

Occupation:   ___________________________________   

Marital status:   Single _______ Married _______   Widowed _______ Divorced _______




REVIEW OF SYSTEMS: Please check off or write in any problems which you have had recently:
_____ skin rash                                                  _____ constipation
_____ skin growth                                             _____ diarrhea
_____ headaches / migraines                            _____ hemorrhoids
_____ visual problems                                      _____ blood in stool
_____ loss of vision                                          _____ hepatitis
_____ hearing loss                                            _____ urinary tract infections
_____ ringing in ears                                        _____ urinary incontinence
_____ nosebleeds                                              _____ pain with urination
_____ nasal drainage                                        _____ kidney stones
_____ history of hay fever, allergies                _____ discharge (urethral/vagina)
_____ sinus problems                                       _____ genital herpes
_____ difficulty swallowing                             _____ history of venereal warts
_____ recurrent strep throats                            _____ HIV
_____ persistent gland swelling                       _____ joint pain or swelling
_____ goiter (enlarged thyroid)                        _____ convulsion or seizure
_____ shortness of breath                                 _____ dizziness
_____ wheezing / asthma                                  _____ depression
_____ persistent cough / bronchitis                  _____ anxiety
_____ history of tuberculosis                            _____ problems handling stress
_____ chest pain                                                _____ difficulty sleeping
_____ Palpitations (extra heartbeat)                  _____ significant weight loss or gain
_____ history of heart murmur                          _____ change in sexual interests or vigor
_____ rheumatic fever                                       _____ bleeding disorder
_____ heart attack / myorcardial infarction       _____ easy bruising
_____ high blood pressure                                 _____ history of blood clots
_____ ulcer                                                        _____ previous blood transfusion
_____ persistent indigestion                              _____ fatigue / lack of energy

FEMALE  PATIENTS
Age of onset of menstrual periods___________                           Last menstrual period   _______________
Date of last Pap test  _____________________                           Pregnancies (dates)      ________________
History of abnormal Pap test _______________                         Live births                    ________________ 
Date of last mammogram _________________                           Miscarriage / Abortion ________________
                                                                                                        Method of birth control _______________