History and Present Illness - Raj Dalal, M.D.



Physician:Raj Dalal, M.D. Internal MedicinePatient Name:(Last, First, M.I.)____________________________________________________________Date of Birth:______________________Date Of Office Visit:________________________Reason for Visit (Complaints)DurationReason for Visit(Complaints)DurationRoutine Visit/Annual Physical Examination/RefillsN/APreventive Health InformationEventM/YearEventM/YearMammogram (For women >40)Prostate Examination(For men > 50)PAP smear (For women >18)PSA (For men >50)Osteoporosis Test (For women > 50 and men > 65)Colonoscopy (for both men and women > 50)Pneumonia Vaccine/ Prevnar 13Aneurysm check (60 or older)Shingles Vaccine (For >50)Tetanus/Td/TDAP VaccinePast Medical HistoryMedical problemYear of eventMedical problemYear SinceHeart attack/StentDiabetesCongestive Heart FailureHigh Blood PressureIrregular HeartAsthma/Emphysema /COPDCancerLocation:________List other medical problems:PneumoniaMigrainesBlood TransfusionStrokeHepatitisGlaucomaPast Surgical ExperienceSurgery/ProcedureYearSurgery/ProcedureYearHospital AdmissionsHospitalReason for admissionYearSocial HistoryHabitNever CurrentFormerQuit yearYears of habitSmoking / pack per dayAlcoholSocial/HeavySocial/Heavy Drug abuseLocal PharmacyMail Pharmacy (if any)AllergiesMedicine allergies Non medicinal allergiesMedicine ListName and dose of medicineHow many times a dayName and dose of medicineHow many times a dayList over the counter medsFamily HistoryDiseaseMotherFatherBrotherSisterAlive/DiedAlive/DiedHigh Blood PressureDiabetes Mellitus Heart DiseaseStrokeHigh CholesterolCancer (location if so)Asthma/ EmphysemaOthersOther complaints or symptoms(Mark “Yes” or “No”)ComplaintsYesNoComplaintsYes NoFeverBody acheMuscle achesWeight LossSore ThroatWeight GainExcessive AppetiteExcessive ThirstCough, Duration_____Nose BleedsSputum , Color______Blood in sputumSinus painNose drainageEar painHearing Loss, Ringing in earHeat intoleranceCold intoleranceNodes or lumps in any part of the bodyExcessive FatigueJaw painSnoring heavilyChest painConstant/IntermittentLocation_____On exertion/at restCharacter of pain- (tightness, squeezing, burning, pressure)Radiation of pain to back, jaw, neck or armShortness Of BreathOn ExertionAt restWhile sleeping at nightSwollen LegsPalpitationsExcessive SweatingBlurred visionHeadaches Duration____One sidedBoth sidedThrobbingLoss of visionAre you bothered by light, sound or movements?Double visionFatigue (Tiredness)Memory lossAny weakness or paralysisAny tingling or numbnessAt times sad/At times greatAnxiety/DepressionSleeplessnessLack of interest in thingsGuilty or worthless feelingSuicidal thoughtsAgitation/AngerAnorexia/Excessive eatingExcessive SleepinessLack of concentrationUnable to complete workImpotency Lack of LibidoAny other complaints to report Seizures or fitsFrequent fallingLoss of sensation on skinIn-coordinationAssociated nausea or vomitingSpeech difficultyDizzinessComplaintsYesNoComplaintsYesNoAny episodes of confusionHave you passed out any time in the past?ConstipationDiarrheaBlood in StoolDark, foul smelling stoolNausea/vomitingHeartburnsDifficulty in swallowingPainful swallowingAbdomen PainLocation________Type (Squeezing/ Burning/Cramp)Does it go to other locations?Joint painBackacheRashDuration___Leg ulcersVaricose veinsCallusesBreasts MassDischargeTenderness/PainNipple inversionColor changesUrinary ProblemsIncontinenceUrgencyFrequencyBurningBlood in urineGynecological IssuesMenstruationRegular/IrregularMenopausalVaginal DischargeVaginal BleedingVisit gynecologist routinelySkinNew molesBlack molesMoles with changes Bleeding mole_____________________________Signature (Patient/Medical Power of attorney)Assessment/ Plan of Care: (Details in the -EMR records) ................
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