Name (Last, First, Middle Initial): ______

Name (last, first, middle initial): ______

Preferred Name: ______Date of Birth:______

Do you have any concerns for today’s visit? Please explain.

______

Past and Ongoing Medical Problems

Please check any of the following problems for which you have received a medical diagnosis.

Condition / Yes / No / Condition / Yes / No / Condition / Yes / No
High Blood Pressure / Glaucoma / Thyroid Disease
High Cholesterol / Cataract / Diabetes
Heart Attack / Anemia / Lupus
Coronary Artery Disease / Heartburn/Reflux / Gout
Angina / Ulcer / Rheumatoid Arthritis
Heart Failure / Hepatitis / Arthritis
Heart Murmur / Liver Disease / Osteoporosis
Blood Clots/Thrombosis / Irritable Bowel Syndrome / Disc Disease/
Herniated Disc
Stroke / Crohn’s Disease or Colitis / Herpes
Memory loss / Gallbladder disease / Chlamydia
Seizure/Epilepsy / Pancreatitis / Gonorrhea
Parkinson’s Disease / Renal Failure / Genital Warts
Headache or Migraine / Kidney Stones / Syphilis
Depression / Frequent UTIs / AIDS/HIV
Anxiety / Prostate Problems / Any other chronic or serious condition:
Asthma / Cancer (type, including skin cancer):
Allergic Rhinitis
Tuberculosis
COPD (emphysema or chronic bronchitis)

Surgeries

Procedure / Date / Place

Hospitalizations

Reason / Date / Place

Patient’s Name: ______Date of Birth: ______

Medications

Please list your current medications, including dosage and when you take it, or attach a list with this information. Include prescribed medications, over the counter medicines and supplements.

Medication / Dosage (milligrams, etc) / Frequency (e.g., every morning) / Prescriber

Allergies

Please list any items to which you are allergic (medications, food, IV contrast, iodine) and the reaction you had.

Item(s) to Which You are Allergic / Reaction

Family History

Do you have knowledge of your genetic family history? YESNO

If yes, please indicate if any of your blood relatives have or have had any of the following diseases.

Condition / Mother / Father / Mother’s Mother / Mother’s Father / Father’s Mother / Father’s Father / Your Siblings
Heart disease
High blood pressure
High cholesterol
Lung disease
Diabetes
Kidney disease
Thyroid disease
Bleeding or clotting disorder
(specify type if known)
Stroke
Cancer (specify type if known)
Mental illness
Suicide
Alcoholism
Obesity
Age at death (if applicable)

Women’s Health History

Age of first menstrual period:_____Date of last menstrual period:______Typical duration: ______

Typically, how many days from the first day of one period to the first day of the next? ______

Are you currently pregnant?YESNOAre you planning a pregnancy? YESNO

If no, what do you do to prevent pregnancy? ______

Total pregnancies: ______Miscarriages: ______Deliveries: ______Children: ______

Age at first pregnancy: ______Age at most recent pregnancy: ______

Have you had any complications with pregnancy or delivery? Please describe. ______

______

Patient’s Name: ______Date of Birth: ______

Personal Habits

Do you currently use tobacco?YESNO(If yes, please answer the following questions.)

What kind? Cigarettes ____Pipe ____Cigar ____Chew ____

Amount/packs per day? ______When did you start? ______

How many times have you attempted to quit? ______Are you interested in quitting? ______

Have you ever used tobacco? YESNO (Ifyes, please answer the following questions if not answered above.)

What kind? Cigarettes ____Pipe ____Cigar ____Chew ____

When did you start? ______When did you quit? ______Amount/packs per day? ______

Do you use any recreational drugs (any illegal drug or prescription drug not prescribed to you)? YESNO (Ifyes, please answer the following questions.)

What type? ______Amount used in a day: ______

How often do you use? ______Have you ever felt the need to quit? ______

Do you use alcohol in any form (beer, wine liquor)? YESNO(If yes, please answer the following questions.)

Type of alcoholic beverage: ______Amount consumed in a day: ______

How often do you drink? ______Have you ever felt the need to cut down? ______

Do you consume caffeine (e.g., colas, coffee, tea, energy drinks, chocolate)? YESNO (Ifyes, please answer the following questions.)

What kind? ______Amount consumed in a day: ______

Do you follow a special diet?YESNOIf yes, please describe: ______

Do you use a nutrition supplement? YESNOIf yes, please describe: ______

Please outline your typical daily food intake.

Breakfast / PM Snack
AM Snack / Dinner
Lunch / Snack
Beverages

On average, how many hours do you sleep each night? ____ Do you have trouble falling or staying asleep? YES NO

Do you use anything to help you fall asleep?YESNOIf yes, what do you use? ______

Do you wake up feeling rested? ______Do you snore? ______Are you drowsy in the daytime? _____

Do you get regular exercise? YESNOIf yes, what type? ______

How many times per week do you exercise? ______How many minutes per day? ______

Are you a current or former member of the military? YESNO (Ifyes, please answer the following questions.)

Dates of serviceFrom: ______To: ______

When and where were you deployed? ______

______

______