Please Check Any Conditions Or Problems That Apply to You

MEDICAL HISTORY

Name: ______Age ______

Please check any conditions or problems that apply to you:

[ ] Angina[ ] Cancer [ ] Diabetes [ ] Asthma

[ ] Heart Attack[ ] Ulcers [ ] High Blood Pressure [ ] COPD

[ ] Blood Clots[ ] Bleeding Tendencies [ ] Kidney Problems[ ] Emphysema

[ ] Blood Thinners[ ] Intestinal Problems [ ] Liver Problems[ ] Anesthesia Problems

[ ] Cardiac Arrhythmia[ ] HIV/AIDS [ ] Hepatitis[ ] Thyroid Problems

[ ] Sleep Apnea[ ] Multiple Sclerosis [ ] Gout[ ] Prostate Problems

[ ] Sickle Cell[ ] Lupus [ ] Rheumatoid Arthritis[ ] Glaucoma

[ ] Other ______

Please check any symptoms that apply to you:

Gen:[ ] Shortness of breath GU:Heme:

[ ] Fever[ ] Leg pain\weakness [ ] Urinary problems[ ] Easy bruising\bleeding

[ ] Feeling Sick when walking [ ] Urinary incontinenceEndocrine:

[ ] Weight lossResp: [ ] Sexual problems[ ] Excessive thirst

Skin:[ ]Wheezing Neuro:[ ] Excessive urination

[ ] Rash\Open sores[ ] Chronic cough [ ] HeadachesMS:

HEENT:GI: [ ] Seizures[ ] Joint swelling\swelling

[ ] Dizziness[ ] Heartburn\reflux [ ] Fainting[ ] Muscle pain

[ ] Vision change[ ] Difficulty swallowing [ ] Loss of balance[ ] Neck pain

[ ] Hearing change[ ] Abdominal pain Psych:[ ] Low back pain

[ ] Sore throat[ ] Nausea\vomiting [ ] Depression[ ] Sciatica

[ ] Ringing in ears[ ] Constipation\ diarrhea [ ] Hallucinations[ ] Numbness\tingling of

CV:[ ] Bloody\tarry stools [ ] Insomnia fingers

[ ] Chest pain[ ] Fecal incontinence [ ] Anxiety[ ] Numbness\tingling of

[ ] Palpitations [ ] Panic attacks feet

List all Prior Surgeries (Include dates):______

Allergies (Include reaction, location, severity, and start date):

Medication: ______

______

Food & Environmental: ______

Ambulatory: [ ]Y [ ]N Cane [ ] Walker [ ] Wheelchair [ ]

Family History:

[ ] Cancer[ ] Heart Disease [ ] Arthritis[ ]Diabetes

[ ] Anesthesia Problems [ ] Other ______

Social:

Do You Smoke? [ ] No [ ] Yes How many packs per day? ______Quit when: ______

Drink Alcohol? [ ] No [ ] Yes How many drinks a day? ______Quit when: ______

Have you ever been addicted to any drug or medication? [ ] No [ ] Yes (name)______

Occupation: ______

______

Date Signature