NAME (LAST, FIRST, MI)



NAME (LAST, FIRST, MI)ID NUMBER:DATE OF BIRTHAGEADDRESS:CITYSTATE/ZIPJOB TITLE:HOME PHONE( )WORK PHONE( )CURRENT MEDICATIONS, DOSE AND FREQUENCY:ALLERGIES:PREVIOUS SURGERY(IES), REASON(S), DATE(S):PREVIOUS HOSPITALIZATION(S), REASON(S), DATES(S)IMMUNIZATIONS:(date)HEALTH MAINTENANCE:(date/results)Tetanus_____________________Cholesterol__________________________________________________Hepatitis B_____________________Hep. B Titer__________________________________________________Flu_____________________Colonoscopy__________________________________________________PSA__________________________________________________CHEST X-RAY_____________________Mammogram & PAP__________________________________________________HAVE YOU EVER HAD ANY OF THE FOLLOWING CONDITIONS?Please answer the following questions honestly and completely. Any “YES” answer must be explained on the last page.YESNOYESNO1. Emphysema18. Angina2. Asthma19. Heart Failure3. Pneumonia20. High Cholesterol4. Pneumothorax21. High Blood Pressure5. Blood Clot in the Lungs22. Arthritis / Rheumatism6. Kidney Disease23. Glaucoma7. Prostatitis24. Epilepsy8. Colitis25. Convulsions / Seizures9. Hepatitis26. Stroke10. Liver Disease27. Diabetes11. Elevated Liver Enzyme Test28. Thyroid Trouble12. Pancreatitis29. Anemia13. Ulcer30. Eczema14. Heart Attack31. Cancer (including skin cancer)15. Heart Murmur32. Sleep Apnea16. Positive Cardiac Stress Test33. Chronic Muscular Disease17. Heart Valve Abnormality34. Chronic Neurological Disease____________________________________________________________________________________________________________REVIEW OF SYMPTOMSDo you currently have or have you recently had any of the following? Explain ALL “YES” answers on the last page.YESNOYESNOEYES / EARS / NOSE THROATCENTRAL NERVOUS SYSTEM35. Difficulty with night vision73. Fainting spells36. Change in vision74. Recurrent dizziness37. Blurred or double vision75. Frequent headaches38. Bleeding gums76. Tremors39. Frequent nose bleeds77. Memory loss40. Frequent sinus trouble78. Loss of coordination41. Recent hoarseness79. Numbness / tingling in extremities42. Ringing / buzzing in the ears80. Loss of consciousness43. Ear ache44. Loss of hearingMUSCULO / SKELETAL81. Back trouble / painPULMONARY82. Neck trouble / pain45. Shortness of breath83. Joint injury / pain / swelling46. Chronic or frequent cough84. Carpal Tunnel Syndrome47. Brown or blood-tinged sputum48. Chest tightnessMENTAL HEALTH49. Wheezing85. Recurrent nightmares50. Chronic bronchitis86. Intrusive images87. Inability to focusGENITO-URINARY88. Difficulty concentrating51. Bladder trouble89. Anxiety52. Blood in urine90. Panic attacks53. Difficulty starting/stopping urination91. Depression54. Urinating 3+ times per night92. Fear of heights55. Frequent or painful urination93. ClaustrophobiaWomen Only56. Currently pregnantMISCELLANEOUS57. Irregular vaginal bleeding94. Bleeding / bruising easily95. Enlarged glandsGASTROINTESTINAL96. Rashes58. Vomiting blood97. Unexplained lumps59. Persistent diarrhea98. Chronic fatigue60. Persistent constipation99. Night sweats61. Frequent abdominal pain100. Undesired weight loss62. Frequent nausea101. Snoring63. Frequent indigestion / heartburn102. Difficulty sleeping64. Black or bloody bowel movement103. Low blood sugar65. Hemorrhoids104. Unexplained fever66. Trouble swallowing105. Decreased stamina67. Hernia106. Any other medical conditionHEART / VASCULAROCCUPATIONAL EXPOSURES68. Palpitations (irregular heartbeat)107. Exposure to noise69. Pain or discomfort in the chest108. Exposure to asbestos70. Swelling of the feet / ankles109. Exposure to heavy metals71. Leg pain while walking110. Exposure to toxic substances72. Painful varicose veins111. Exposure to hazardous materialsEMPLOYMENT HISTORYEmployerGeneral Job DutiesYears in PositionFAMILY AND SOCIAL HISTORYYESNODoes anyone in your immediate family: Have a history of heart disease or stroke?Have cancer?Have high blood pressure?Have diabetes?Do you smoke? cigarettes cigars smokeless / chewing tobacco / snuff_____________ number per day _____________ yearsHave you quit smoking?_____________ when quit _____________ years smoked before quittingDo you drink alcohol?_____________ type _____________ number of drinks per day / weekDo you exercise regularly?Type:Frequency:Do you wear contact lenses? If checked: □ hard lenses or □ soft lensesDo you wear glasses?EXPLANATIONS TO “YES” ANSWERS QUESTION #EXPLANATION ................
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