(Medical History Form)

PATIENT INTAKE HISTORY


All information is kept confidential. If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.


Patient Name
Patient Name:


General Medical History
Alcohol/drug Addiction Anemia Arrhythmia
Arthritis Asthma Bleeding disorder
Blood clots Blood transfusions Bowel problems
Broken bones Cancer Cataracts
Chickenpox Collagen vascular disease Depression/anxiety
Diabetes Eating disorder Gallbladder disease
Glaucoma Headaches Heart disease/attacks
Heart murmur Hepatitis High blood pressure
High cholesterol HIV/AIDS Joint/back pain
Kidney infections Kidney stones Lung disease
Osteoporosis Pneumonia Reflux/ulcers
Rheumatic fever Seizures/epilepsy Sickle cell
Stroke Thyroid disease Tuberculosis
Other:   None  


Past Surgical/Injury History
DateSurgery/Injury
None


Allergies
Drug/Food/Other TriggerReaction
None


Medications
(Please include all hormones, vitamins, herbs, and non prescription medications)
Drug Name / Dose
Drug Name / Dose
None


Patient Information
Sexual Orientation:
Marital Status:
Number of people living in your household:
Current or most recent job:
Travel outside the US?
Have you ever smoked?
Number of packs per day:
Number of years:
Alcohol:
Drinks per day:
Drinks per week:
Have you ever used recreational drugs?
Do you exercise regularly?
Please quantify your dairy intake or calcium supplement usage:
Please quantify your daily caffeine intake:
Have you been sexually abused, threatened or hurt by anyone?


Family History
Mother:
Cause/Age:
Father:
Cause/Age:
Living siblings:
Deceased siblings:
Cause/Age:
Children:
Deceased siblings:
Cause/Age:


Family history of the following:
Alcohol/drug Addiction Alzheimer's Birth Defects
Blood clots Breast Cancer Colon Cancer
Cystic Fibrosis Diabetes Heart Disease/Attack
Hepatitis High Blood Pressure High Cholesterol
HIV/AIDS Mental Illness/Depression Osteoporosis
Ovarian Cancer Stroke Tuberculosis
Uterine Cancer Thyroid Disorder Other:  


Gynecological History
First day of your last menstrual period (mm/dd/yyyy):
Age at your first period:
Usual number of days of bleeding with menses:
How often do you have periods (i.e. every 28 days)?
Any menstrual abnormalities?
Age at menopause:
Have you ever had sex?
Are you currently sexually active?
Are your sex partners:
Any history of sexually transmitted diseases?
Present method of birth control:
Have you ever used birth control or hormone replacement therapy?
If yes, which and for how long?
When was your last PAP test?
Have you ever had an abnormal PAP?
Do you have regular breast self-exams?
Date of last mammogram? (mm/dd/yyyy):


Obstetric History
Please include information about all pregnancies births, miscarriages, abortions, and ectopic (tubal).
 DateWeightSexPlace DeliveredType of DeliveryComplications
     #1:
     #2:
     #3:
     #4:
None


Immunizations
ImmunizationDate (mm/dd/yyyy)
Tetanus-Diphtheria Booster:
Pneumoccocal Vaccine:
Varicella Vaccine:
Flu Shot:
Hepatitus B Vaccine:
Measles-Mumps-Rubella Vaccine:
Pharmacy Name:
Pharmacy Phone Number:
Pharmacy Address:

REVIEW OF SYSTEMS


Please check any of the following symptoms that apply to you.


Constitutional
Change in appetite Change in height Decreased libido Difficulty sleeping
Fatigue Fever Night sweats Weight loss
Weight gain  
Other:  


Eyes
Blurred vision Double vision Glasses/contacts Spots before eyes
Vision changes  
Other:  


Ear, Nose and Throat
Congestion Dental problems Difficulty swallowing Earaches
Hearing problems Mouth sores Neck mass Neck stiffness/pain
Nose bleeds/bleeding gums Recurrent ear infections Ringing in ears Runny nose
Seasonal allergies Sinus problems Sore throat  
Other:  


Cardiovascular
Chest pain or pressure Leg pain Leg swelling Palpitations
Rapid or irregular heart beat Varicose veins Difficulty breathing with exertion Difficulty breathing when lying flat
Other:  


Respiratory
Chronic cough Coughing up blood Painful breathing Shortness
Rapid or irregular heart beat Varicose veins Difficulty breathing with exertion Difficulty breathing when lying flat
Other:  


Gastrointestinal
Abdominal mass Abdominal pain Black stools Bloody stools
Constipation Diarrhea Hemorroids Incontinence of stool or gas
Indigestion Jaundice Nausea/vomitting Rectal pain
Other:  


Genitourinary
Abdominal bleeding Absence of periods Blood in urine DES exposure
Fibroids Frequent bladder infections Frequent urination History of endometriosis
Incomplete emptying Incontinence of urine Infertility Pain with urination
Painful intercourse Painful periods Pelvic pain Premenstrual syndrome
Urgency to urinate Vaginal discharge Vaginal dryness Vaginal itching
Other:  


Musculoskeletal
Back pain Joint pain/stiffness Joint swelling Muscle pain
Muscle weakness  
Other:  


Skin
Acne Discoloration Dry skin Easy bruising
Enlarged lymph nodes Itching Moles Rash
Sores  
Other:  


Breasts
Breast mass Breast pain Breast swelling Nipple discharge/blood
Other:  


Neurologic
Difficulty walking Dizziness Headaches Memory problems
Numbness Seizures Tremor  
Other:  


Psychiatric
Anxiety Depression Frequent crying             
Other:  


Endocrine
Abnormal hair growth Abnormal thirst Deepening of voice Hair loss
Heat/cold intolerance Hot flashes  
Other: