DEPARTMENT OF SURGERY

Patient’s personal history

LAST NAME FIRST NAME MIDDLE DATE

INITIAL

5M 5F 5 S 5M 5D 5W

DOB AGE HT WT SEX MARITAL STATUS OCCUPATION

BP HR RR PAIN LEVEL (1-10)

CHIEF COMPLAINT / REASON FOR TODAY’S VISIT:

HISTORY OF PRESENT ILLNESS:

LIST ALL MEDICATIONS CURRENTLY TAKING (INCLUDE HERBAL MEDS/ SUPPLEMENTS):

LIST ALL KNOWN DRUG ALLERGIES:

PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY:

SOCIAL HISTORY: DRINK ALCOHOL 5 YES 5 NO IF YES, HOW OFTEN DAILY, HOW MANY YEARS

SMOKE 5 YES 5 NO IF YES, HOW OFTEN DAILY, HOW MANY YEARS

RECREATIONAL

DRUGS 5 YES 5 NO IF YES, TYPE & HOW OFTEN DAILY, HOW MANY YEARS

FAMILY HISTORY (GRANDPARENTS, PARENTS, SIBLINGS, CHILDREN):

RECENT DIAGNOSTIC PROCEDURES DONE:

REVIEW OF SYSTEMS

GENERAL / NO / YES / EYES / NO / YES / MUSCULOSKELETAL / NO / YES
Significant weight changes / Change in vision / Back pain
Fatigue / Pain / Joint pain/swelling
Weakness / Redness / Muscle pain
Fever/Chills / Double Vision / Varicose veins
Easy bleeding/bruising / Leg ulcers
NOSE / THROAT / SKIN
Colds / Trouble swallowing / Redness
Sinus Problems / Hoarseness / Rash
Stuffiness / Frequent sore throat / Nodule
Nose Bleeds / Swollen glands / Easy bruising
EARS / ENDOCRINE / GENITOURINARY
Ringing / Diabetes / Painful urination
Hearing loss / Thyroid problems / Frequent urination
MOUTH / Heat/cold intolerance / Blood in urine
Bleeding gums / Excessive urination / Urinary tract infections
Dental problems / Sweaty / Kidney stones
Kidney disease
Urinary incontinence
NEURO/PSYCH / RESPIRATORY / GYNECOLOGICAL
Headache / Cough / Number of pregnancies ____
Fainting / Blood/Sputum / Number of births _____
Seizures / Shortness of breath / Vaginal _____
Paralysis / Wheezing / C-section _____
Mental Illness / Asthma / Abortion _____
Stroke / Bronchitis / Non-menstrual bleeding
Memory Loss / Emphysema / Pelvic pain
Anxiety / Pneumonia / Breast lumps
Depression / Tuberculosis / Nipple discharge
Disturbing feelings/thoughts / Sleep Apnea / Last mammogram
CARDIOVASCULAR / GASTROINTESTINAL / PHYSICAL ACTIVITY
High/Low blood pressure / Change in appetite / 1.  None
Murmurs / Heartburn / 2. Little
Chest pain / Abdominal pain / 3. Moderate
Irregular heart beat / Nausea / 4. Very Active
Heart disease / Vomiting
History of blood clots / Colitis / Stair Climbing
Circulation problems / Diarrhea / Number of flights ______
Anemia / Constipation
Blood Transfusions / Liver disease
Leg/ankle swelling / Hepatitis
Easy bleeding/bruising / Hernias / Other:
Anal/rectal pain
Anal/rectal bleeding
Change in bowel habits
Fecal incontinence
Last Colonoscopy

PATIENT SIGNATURE DATE PHYSICIAN SIGNATURE DATE