Rita Rodgers- Stanley

Rita Rodgers- Stanley M.D.

Health History

(Confidential)

Name______Today’s Date______

Age______Birthdate______Social Security Number ______

What is your reason for visit?______E-Mail ______

SYMPTOMS CHECK(√) symptoms you CURRENTLY HAVE or have had IN THE PAST YEAR.
GENERAL GASTROINTESTINAL EYE, EAR, NOSE, THROAT MEN ONLY
□Depression□Appetite poor□Bleeding gums□Erection difficulties
□Dizziness□Bloating□Blurred vision□Lump in testicles
□Fever□Constipation□Difficulty swallowing□Penis discharge □Forgetfulness □Diarrhea □Double vision □Sore on penis □Headache □Gas □Hay fever □Loss of Sleep □Hemorrhoids □Loss of hearing WOMEN ONLY □Loss of weight □Indigestion □Nose bleed □Abnormal Pap Smear □Nervousness □Nausea/Vomiting □Persistent cough □Extreme menstrual pain □Numbness □Rectal bleeding □Ringing ears □Hot flashes □Sweats □Stomach pain □Sinus problems □Menstrual changes □Vomiting blood □Nipple discharge □Painful intercourse □Vaginal discharge
Muscle/Joint/Bone CARDIOVASCULAR SKIN Date of last
Pain, weakness, numbness in:□Chest pain□Bruise easily menstrual period__
□Arms □Hips□Irregular heart beat□Itching Date of last
□Back □Knees□Poor circulation□Change in moles Pap Smear______
□Feet □Neck □Swelling of ankles/feet□Rash Date of last
□Hands □Shoulders □Sore that won’t heal mammogram______GENITO-URINARY Are you pregnant? ______□Blood in urine
□Frequent urination
□Lack of bladder control
□Painful urination
CONDITIONS Check (√) conditions you have or have had in the past.
□AIDS □Diabetes□High Cholesterol□Seizures
□Alcoholism□Eating Disorder□HIV Positive □Stroke
□Anemia□Emphysema□Kidney Disease□Suicide Attempt
□Appendicitis□Glaucoma□Liver Disease□Thyroid Problems
□Arthritis□Gonorrhea□Migraine Headaches□Tonsillitis
□Asthma□Gout□Miscarriages□Tuberculosis
□Breast Lump□Heart Disease□Multiple Sclerosis□Ulcers
□Bronchitis□Hepatitis□Pacemaker□Vaginal Infections
□Cancer□Hernia□Pneumonia□Venereal Disease
□Cataracts□Herpes□Prostate Problem
□Chemical Dependency□High Blood Pressure□Psychiatric Care
Medications List medications you are currently taking.
ALLERGIES To medications or substances
Pharmacy Name______Number______

(All information is strictly confidential)

Family HistoryFill in health information about your family.
Relation / Age / State of Health / Age at Death / Cause of Death / Check (√) if, your blood relatives had any of the following:
Disease Relationship to you
Father / Arthritis, Gout
Mother / Asthma, Hay fever
Brothers / Cancer
Chemical Dependency
Diabetes
Heart Disease, Stroke
Sisters / High Blood Pressure
Kidney Disease
Tuberculosis
Other
Hospitalizations
Year Hospital Reason for Hospitalization and Outcome / Pregnancy History
Year of Birth Sex of Birth Complications if any
Sexual History- / Do you have intercourse with…….
□ Men □ Women □ Both
Have you ever had a blood transfusion? □Yes □No
If yes, please give approximate dates.______/ Health Habits Check (√) which substance you use and describe how much you use.
SERIOUS ILLNESS/INJURIES / DATE / OUTCOME / Caffeine / Coffee
Tea
Soda
Tobacco / Cigarettes
Cigars
Chewing Tobacco
Drugs
Alcohol
Other
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Signature: ______Date:______
Address______
City/State/Zip______
Telephone______ / Occupational Concerns
Check (√) if your work exposes you to the following:
Stress
Hazardous Substances
Heavy Lifting
Other
Your occupation:

Fax completed form to 800/556-4966

OVER

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