MEDICAL HISTORY
MEDICAL HISTORY
|Name | |Date of Birth | |Age | |
|Occupation/Job Title | |
|HEIGHT | |PRESENT WEIGHT | | | |
The following information is necessary to help your doctor make important decisions regarding your medical care. Please answer the questions thoroughly.
|CHIEF COMPLAINT (Explain why you are here to see the doctor) |
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|MEDICAL HISTORY Do you have (or have you had): (Explain in the space available) |
|yes |no | |yes |
|Other (Not mentioned above) | |
|PREVIOUS SURGERIES NONE |
|(Check all that apply; indicate the year of the surgery) |
| Cosmetic (Please list) | |
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| Ear | Thyroid |
| Tonsils | Gallbladder |
| Neck | Appendectomy |
| Nasal | Hemorrhoid |
| Sinus | Colon |
| Eye (Type of surgery) | | Gastric Bypass |
| | Hernia |
| Eyelid | Stomach |
| Breast (Type of surgery) | | Hysterectomy |
| | C-section |
| Back (Type of surgery) | | Heart |
| | Coronary Artery Bypass |
| Joints (Please list which) | | Carotid Bypass |
| | Peripheral Vascular |
|Other (Please list) | |
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|yes |no | |
| | |Have you ever had a problem with anesthesia? |
| |What type of problem? | |
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|PREVIOUS ACCIDENTS/INJURIES | |
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|HOSPITALIZATIONS/EMERGENCY ROOM VISITS (within the last year) | |
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|MEDICATIONS NONE |
|List any current or recent medications. INCLUDE THE DOSAGE. Use the back of this page if necessary. |
|Medicine | |Indications | |Dosage |
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|Do you take any of the following homeopathic products or dietary supplements? |
|yes |no | |
|ALLERGIES NONE |
|List any medication allergies. INCLUDE WHAT HAPPENS TO YOU when you take this medication. |
|Medicine | |Side Effect/Allergic Reaction |
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|SOCIAL HISTORY |
|Occupation: | |How long? | |
|Are you presently single, married, separated, divorced, or widowed? (Circle) |
|Smoking: | |Packs per day. |How many years? | | Never Smoked |
| | Previously smoked up to | |packs per day; date quit | | |
|Alcohol consumption: | |drinks per (day / week / month) of (beer / wine / liquor) (Circle) |
|Do you use, or have you used, any recreational drugs? Yes No (List) | |
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|REVIEW OF SYSTEMS If yes, please indicate if you are currently experiencing any of these symptoms) |
|Constitutional |
|Yes |no | |yes |no | |
| | |In generally good health | | |Fever |
| | |Recent weight change | | |Night sweats |
| | |Chills | | |Chronic fatigue |
|Eyes/Vision |
|yes |no | |yes |no | |
| | |Eye disease or injury | | |Glasses |
| | |Dry eyes | | |Contact lenses |
| | |Blurred/Double vision | | | |
|Ears, Nose, Throat |
|yes |no | |yes |no | |
| | |Hearing loss | | |Nose bleeds |
| | |Ringing in the ears | | |Mouth sores |
| | |Earaches or drainage | | |Voice changes |
| | |Sinus problems | | |Swollen glands in the neck |
|Heart/Cardiovascular |
|yes |no | |yes |no | |
| | |Heart trouble | | |Swelling of feet, ankles, or hands |
| | |Chest pains | | |Heart murmur |
| | |Palpitations | | | |
|Respiratory |
|yes |no | |yes |no | |
| | |Chronic cough | | |Coughing up blood |
| | |Shortness of breath | | |Wheezing |
|Gastrointestinal |
|yes |no | |yes |no | |
| | |Heartburn | | |Constipation |
| | |Nausea or vomiting | | |Blood in the stool |
| | |Stomach pain | | |Changes in bowel habits |
| | |Frequent diarrhea | | | |
|Genitourinary |
|yes |no | |yes |no | |
| | |Frequent urination | | |Painful periods |
| | |Burning or painful urination |First menstrual period | |
| | |Blood in urine |Last menstrual period | |
| | |Incontinence |Number of pregnancies | |
| | |Vaginal discharge |Number of children | |
|Musculoskeletal |
|yes |no | |yes |no | |
| | |Joint pain | | |Muscle pain |
| | |Joint stiffness or swelling | | |Chronic neck pain |
| | |Muscle weakness | | |Chronic back pain |
|Skin And Breasts |
|yes |no | |yes |no | |
| | |Rashes or itching | | |Breast pain |
| | |Palpable lumps or nodules | | |Nipple inversion |
| | |Skin cancer | | |Nipple discharge |
| | |Fibrocystic breast disease |Present bra size: | |
|Date/Result of last mammogram: | |
|Neurologic |
|yes |no | |yes |no | |
| | |Migraine headaches | | |Numbness or tingling sensations |
| | |Dizziness | | |Weakness |
| | |Blackouts | | | |
|Endocrine |
|yes |no | |yes |no | |
| | |Excessive thirst or urination | | |Tremors |
| | |Dry skin | | |Heat or cold intolerance |
|Hematologic/Lymphatic |
|yes |no | |yes |no | |
| | |Easily bruise or bleed | | |Swollen glands |
| | |Blood transfusion | | | |
|Psychiatric |
|yes |no | |yes |no | |
| | |Memory loss | | |Depression |
| | |Nervousness/Anxiety | | |Insomnia |
|Who is your psychiatrist? | |
|Who is your psychologist? | |
|For what condition? | |
|yes |no | |
| | |Have you discussed having surgery with him/her? |
| | |May I discuss your surgery with your psychiatrist/psychologist? |
| | |Does he/she have you on any medications? Which? | |
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|FAMILY HISTORY Is there a family history of any of the following problems? |
|yes |no | |yes |no | |
| | |Ovarian Cancer | | |Diabetes Mellitus |
| | |Colon Cancer | | |Heart Disease |
| | | | | |Bleeding Problems |
| | |Breast Cancer |Who? | |
| | |Age Diagnosed: | |
| | |Other Cancer | |
| | |Other Conditions: (Refer to Page 1) | |
| | |Anesthesia Problems (What type of problem?) | |
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|Parents |
|Mother | Alive | Deceased |Cause of death: | |
|Father | Alive | Deceased |Cause of death: | |
|All of the foregoing is true to the best of my knowledge. |
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|Patient Signature Date |
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