Name Age Occupation

(if retired, former occupation)

Marital status Height Weight

Previous Physicians

Primary Care Physician(s) / Last seen:
Specialist Physician(s) / Last seen:

Allergies:

Vaccinations:

(most recent date)

Flu Pneumonia

Tetanus Hepatitis

Measles Rubella

Mumps Polio

Other

Health Habits:

Cigarettes

pkg/day yrs

Quit? Date

Alcohol

drinks per week

Quit? Date

Coffee and/or tea

cups per day

Do you use seatbelts? Yes ____ No ____

Have you ever been treated for substance abuse?

Facility / Date

Medication You Currently Use (prescription or not)

Primary Health Concern or Complaint:

Test, X-rays & Exams

Most recent date

EKG (Heart) ......

Chest X-Rays ......

Mammogram ......

Blood test ......

Eye exam ......

HIV test ......

TB test ......

Valley Fever test . . . . .

Gallbladder X-ray . . . .

Upper GI X-ray ......

Upper Endoscopy . . . . .

Barium Enema ......

Colonosopy ......

MRI scan ......

CT scan ......

EEG (Brain) ......

Treadmill ......

Heart catherization . . . .

Blood Transfusion . . . .

Other:

Past Medical Illness:

(Check if “Yes” )

Measles ......

Mumps ......

Chicken Pox ......

Rubella ......

Diphtheria ......

Polio ......

Rheumatic Fever ......

Meningitis ......

Herpes Zoster ......

Shingles ......

Herpes Simplex ......

Hepatitis ......

Valley Fever ......

Tuberculosis ......

Typhoid Fever ......

Whooping Cough . . . . .

Meningitis ......

Encephalitis ......

Diabetes ......

Hypertension ......

Stroke ......

Heart Attack ......

Past Surgery

(Check if “Yes”)

Tonsillectomy ......

Appendectomy ......

Hysterectomy ......

Gallbladder ......

Colon ......

Skin biopsy ......

Heart......

Stomach ......

Eye ......

Bone or Joint ......

Back or Spine ......

Breast ......

Symptoms & Complaints

(Check if “Yes”)

Sinus infection ......

Allergy of hay fever ......

Dentures ......

Dental problems ......

Double vision ......

Lens implant ......

Hearing problem ......

BreastPain ......

Lumps ......

Cyst ......

Had biopsy ......

Consulted surgeon . . .

Have had pneumonia ......

Frequent chest colds ......

Exposure to TB ......

Persistent cough ......

Cough up blood ......

Cough up pus ......

Frequent bronchitis ......

Short of breath ......

Wheezing or asthma ......

Emphysema ......

Chest pain/pressure ......

Exertion caused chest ......

Pain/pressure ......

Use of heart medications ......

Prior heart attack ......

Irregular heart beats ......

Heart “flutters ......

Have consulted a cardiologist . .

Stomach ulcers ......

Hiatal Hernia ......

Regurgitation food ......

Regurgitation acid ......

Frequent nausea ......

Intolerance of rich of ......

Fatty foods ......

Gallbladder disease ......

Diverticulitis ......

Vomiting blood ......

Blood in stool ......

Black, tarry stool ......

Use of stomach or colon medicines

Symptoms & Complaints

(Check if “Yes”)

Had kidney stones ......
Blood in urine ......
Painful urination ......
Trouble starting urine ......
Dribbling urine ......
Incontinence ......
Do you need to get up to urinate during the night?
Had a CVA (stroke) ......
Paralysis or loss of feeling ......
Had seizures ......
Loss of consciousness ......
Have consulted a neurologist . . . . .

Symptoms & Complaints

(Check if “Yes”)

Arthritis ......
Past fractures ......
Injuries to bones, muscles, or joints . .
Back pain or strain ......
Sciatica ......
Pain in wrist and/or hands ......
Skin cancer ......
Rash ......
Abscess ......
Cyst ......
Skin nodule ......

Family Health History

(Check to indicate any conditions experienced by family members)

Mother

/

Father

/ Sister / Brother / Child

Cancer

Heart Disease
Stroke
Paralysis
Parkinson’s Disease
Alzheimer’s Disease
Epilspsy
Asthma
Diabetes
Thyroid problem
Bleeding problem
Blood clots; phlebities
Mental disorder
Anemia
Age at Death
Cause of death

Female Patients Only please answer these additional questions

Menstrual Cycle

1st period at age

Date of last period

Frequency of periods

Any cramps or heavy flow?

Any bleeding between periods?

any missed or irregular periods?

Date of last pelvic exam

Ever had a D&C?

Do you have breast implants?

Type

Any problems with:

vaginal yeast infection?

trichomonas infection?

Pregnancy

Number of:

pregnancies

live births

miscarriages

abortions

C-sections