Valley Health Internal Medicine Ranson

Valley Health Internal Medicine|Ranson

NameDate of Birth

Patient History

Please take the time to complete the following information as accurately as possible. This information will be kept confidential and will help your health care provider with diagnosis and treatment.

Medical History

Medical Illness or ConditionDate Diagnosed

______

Surgical History

Surgery or Operation Date

______

Patient History, continued

Medications (please include any oral or injectable medicine, prescribed cream, gel or patch, as well as any vitamins, minerals or supplements taken)

Medication or SupplementDosageTimes per Day

______

Allergies/Adverse Reactions to Medications

MedicationReactionDate

______

Patient History, continued Review of Systems(p1)

GeneralYes No

Do you usually feel tired or worn out? ☐ ☐

Have you recently noticed that heat or warm weather bothers you? ☐ ☐

Do you feel too hot or too cold? ☐ ☐

Do you have night sweats? ☐ ☐

Have you had any unusual weight gain or loss in past 6 months? ☐ ☐

Infectious Disease Yes No

Have you ever tested positive for Tuberculosis?☐ ☐

Have you ever tested positive for HIV (AIDS virus)?☐ ☐

Have you ever had infectious hepatitis?☐ ☐

Skin Yes No

Have you noticed rashes or change in coloration of your skin?☐ ☐

Have you noticed any growths on your skin that concerns you? ☐ ☐

Have you noticed sores or wounds that don’t heal?☐ ☐

Have you noticed increased scalp hair loss?☐ ☐

Has your skin become drier recently?☐ ☐

Do you have acne? ☐ ☐
Do you have excessive hair growth?☐ ☐

Eyes, Ears, Nose, Throat Yes No

Do you have blurred vision, eye pain, or trouble focusing ☐☐

Do you have any trouble hearing?☐☐

Do you have ringing or buzzing in your ears?☐☐

Do you have any sores or unusual dryness of your mouth?☐☐

Do you have persistent hoarseness?☐☐

Do you have any enlargement in your neck? ☐☐

Have you noticed any lumps in your neck? ☐☐

Do you have hay fever or seasonal allergies? ☐☐

Respiratory Yes No

Do you have a constant or bothersome cough?☐ ☐

Do you have frequent chest colds?☐ ☐

Do you have difficulty breathing?☐ ☐

Have you coughed up blood?☐ ☐

Have you noticed any wheezing?☐☐

Cardiovascular Yes No

Do you have pain, tightness or pressure in your chest?☐☐

If yes, does it occur when walking fast, working hard, or excited?☐☐

Do you have swelling of your feet or ankles?☐☐
Does your heart ever beat fast, irregularly or skips beats?☐☐

Do you have pain or tightness in your legs when walking?☐☐

Patient History, continued Review of Systems(p2)

Gastrointestinal Yes No

Do you have a poor appetite?☐☐

Are there any foods that cause you to have upset stomach?☐☐

Have you recently noted any trouble swallowing?☐☐

Do you have a lot of heartburn or indigestion?☐☐

Have you ever vomited blood?☐☐

Do you suffer from constipation or irritable bowel syndrome?☐☐

Do you have frequent loose stools or diarrhea?☐☐

Have you ever passed blood from your rectum?☐☐

Have you ever had black or tarry stools?☐☐

Have you noticed any recent change in your bowel habits?☐☐

Do you have frequent nausea or vomiting?☐☐

Have you ever had an ulcer?☐☐

Have you ever had colon polyps?☐☐

Have you ever had jaundice or liver disease?☐☐

Genituorinary Yes No

Do you have pain or burning when you urinate?☐☐

Do you have to urinate frequently?☐☐

Do you have trouble passing your urine?☐☐

Do you get up at night to urinate? How many times?______☐☐

Do you have trouble losing your urine when you cough or sneeze?☐☐

Have you ever passed blood in your urine? ☐☐

Have you ever had a kidney stone? ☐☐

Do you have a problem with sexual drive or function?☐☐

Women Only

Age at first menstrual cycle: ______

Date of last menstrual period: ______

Method of birth control: ______

Date of last PAP smear: ______

Are your menstrual periods irregular?☐ ☐

Do you have discharge from your nipples?☐ ☐

How many pregnancies? ______miscarriages? ______abortions?______

Musculoskeletal Yes No

Do you have persistent back pain or stiffness?☐☐

Do you have muscle pain or weakness?☐☐

Do you have swelling, pain or stiffness in your joints?☐☐

Do you have muscle cramps?☐☐

Have you noticed any change in your shoe or ring size?☐☐

Patient History, continued Review of Systems(p3)

Nervous System Yes No

Do you have frequent or severe headaches? ☐ ☐

Do you have spells of dizziness, faintness or giddiness?☐ ☐

Do you have trouble with your memory?☐ ☐

Have you ever had seizures, convulsions or fits?☐ ☐

Do you have numbness or tingling in hands, arms, legs or feet?☐ ☐

Do you consider yourself a nervous person?☐ ☐

Do you cry a lot for no apparent reason?☐ ☐

Do you feel depressed a lot of the time?☐ ☐
Do you have problems getting to sleep or staying asleep?☐ ☐

Have you ever seen a counselor, therapist or psychiatrist?☐ ☐

Immunizations:

Do you get regular flu shots?

Yes ☐ No ☐ Date of last flu shot:

Have you ever had a pneumococcal (pneumovax) Vaccine?

Yes ☐ No ☐ Date

Have you had a Tetanus Vaccine in the past 10 years?

Yes ☐ No ☐ Date

Have you ever had a shingles (Zostavax) Vaccine?

Yes ☐ No ☐ Date

LifeStyle and Habits:

Tobacco

Have you ever used the following tobacco products?

☐Cigarettes ☐Cigar ☐ Pipe ☐ Chew or Snuff ☐ None

If yes, how many cigarettes, cigars, pipes or cans per day?

How many years have you been smoking?______

If you smoked in the past, when did you quit?______

Alcohol

Do you drink alcohol? ☐never ☐rarely ☐occasionally ☐daily

How much and what kind?______

Coffee/Tea/Soft Drinks

How many cups of coffee or tea and how many soft drinks do you drink per day on average?______

Recreational Drug Use

Have you ever used drugs such as Marijuana, cocaine, etc? Yes☐ No ☐

If yes, which drugs and when?______

Have you ever injected drugs into your veins? Yes ☐ No ☐

Patient History, continued

Occupation

What kind of work do you do? ______

Are you married? Yes ☐No ☐

Who lives with you? ______

Have you had recent significant life stresses? Yes ☐No ☐

If yes, please detail: ______

Dietary Habits______

Exercise Habits______

Hobbies______

Family History:

Gender Living Age Health problems (or cause of death)

Father Y☐N☐

Mother Y☐N☐

Siblings M☐F☐ Y☐N☐ M☐F☐ Y☐N☐

M☐F☐ Y☐N☐

ChildrenM☐F☐ Y☐N☐ M☐F☐ Y☐N☐

M☐F☐ Y☐N☐

Check yes if any blood relative has or has had any of the following diseases

Illness / Yes / Relationship / Illness / Yes / Relationship
High cholesterol / Diabetes
High blood pressure / Thyroid Disorder
Kidney Disease / Kidney Stones
Heart Attack / Osteoporosis
Stroke / Broken Hip
Depression / Adrenal Disease
Blood Disorder / Pituitary Disease
Early Menopause / Cancer
Polycystic ovaries / What type of cancer?

Patient SignatureDate

Patient History, continued

Diabetes Questionnaire

Please complete these two pages only if you have Diabetes.

Also please remember to bring your glucose meter and blood sugar log to this and every appointment.

When was your diabetes diagnosed? ______

What symptoms were you having? ______

Were you told you were: Type 1______Type 2 ______

Gestational (diabetes of pregnancy) ______not told/unsure______

What treatment were you started on? Diet and exercise only ☐ Oral Medications ☐ Insulin ☐ other injectable Medication ☐

What treatment are you on now? Diet and exercise only ☐ Oral Medications ☐ Insulin injections ☐ other injectable Medication ☐

Insulin pump ☐

What is your current insulin dose (if applicable)?

Morning: ______

Lunch: ______

Supper: ______

Bedtime: ______

Have you been to a diabetes educator? Yes ☐No ☐

If yes, when and where was your last visit? ______

Have you been to a dietitian? Yes ☐No ☐

If yes, when and where was your last visit? ______

What diet do you follow?

No particular diet ☐ Watch portions and sweets ☐ Exchange diet ☐ strict carbohydrate counting ☐ “Guesstimate” carbohydrate counting ☐

Do you test your blood sugars? Yes ☐No ☐

If yes, how many times per day? ______

What are the results (on average)?

Morning: ______

Lunch: ______

Supper: ______

Bedtime: ______

Other: ______

Patient History, continued

Diabetes Questionnaire

Do you have low blood sugar reactions? Never ☐Rarely ☐Frequently ☐ How often? ______

If yes, are these low blood sugars Mild ☐Moderate ☐Severe☐

Have you ever passed out from low blood sugar? Yes ☐No ☐

If you do have low sugar, how do you treat this? ______

______

Do you have a medical alert bracelet or necklace? Yes ☐No ☐

Do you wear it regularly? Yes ☐No ☐

Do you have a Glucagon Emergency Kit? Yes ☐No ☐Notsure☐

Have you ever been treated in the emergency room or hospitalized for any of the following?

Low blood sugar Yes ☐No ☐ Not sure☐

High blood sugar Yes ☐No ☐ Not sure☐

Diabetic Ketoacidosis Yes ☐No ☐ Not sure☐

If yes to any, please give dates and details below:

______

Do you have any diabetes related problems with your

Eyes Yes ☐No ☐

Kidneys Yes ☐No ☐

Nerves Yes ☐No ☐

Feet Yes ☐No ☐

Heart Yes ☐No ☐

Circulation Yes ☐No ☐

When was your last appointment with an eye doctor? ______

When was your last appointment with a dentist? ______

What problems or questions do you have concerning your diabetes, or why were you referred for this appointment?

______

Patient Signature______

Valley Health Internal Medicine|Ranson Medicine Patient History