Referring Provider or Individual



ANH VAN NGUYEN, MD., PA. PATIENT NAME __________________

Drug Allergies: ___________________________________________________________

Current Medications: ______________________________________________________

________________________________________________________________________

Your main reason for today’s visit: ___________________________________________

Do you: Smoke ___ (if yes: packs/day: ___ x ___ years) Drink? ___ (if yes, ___ glass/day)

# of Children ___ Ages _______

Please circle the following symptoms that you may have and explain:

Fever Chills Night sweats Weight changes __________________________________

Blurry vision Double vision Light sensitivity _________________________________

Nose bleeds Hearing loss Ringing in ears ____________________________________

Chest pain Murmurs Palpitation __________________________________________

Cough Sputum Wheezing Shortness of breath _______________________________

Nausea Vomiting Abdominal pain Diarrhea Bloody/black stool Appetite changes _

Painful urination Frequent urination Bloody urine Incontinence _________________

Joint pain Muscle pain Weakness __________________________________________

Changes in moles New moles Itching Rashes ________________________________

Loss of balance Dizziness Confusion Headache Numbness Seizures Fainting ____

Abnormal ideation Anxiety Depression ______________________________________

Anemia Bleeding problems Lymphedema ____________________________________

Current or past conditions/surgeries that you may have (please give details):

AIDS/HIV ______________________________________________________________

Head/Eyes/Ears/Nose/Throat/Mouth __________________________________________

Heart __________________________________________________________________

Lungs __________________________________________________________________

Digestive system _________________________________________________________

Urinary system ___________________________________________________________

Reproductive system ______________________________________________________

Skin disorders ____________________________________________________________

Neurologic/Psychological disorders __________________________________________

Thyroid/Diabetes/Hormonal problems ________________________________________

Prosthesis/Implants _______________________________________________________

Others __________________________________________________________________

Please check the following diseases that your relatives may have (please give details):

Disease Mother Father Siblings Children

Asthma __ __ __ __ ________________________

Cancers __ __ __ __ ________________________

Diabetes __ __ __ __ ________________________

Eczema __ __ __ __ ________________________

Heart Diseases __ __ __ __ ________________________

Inflammatory bowel __ __ __ __ ________________________

Lung diseases __ __ __ __ ________________________

Lupus __ __ __ __ ________________________

Malignant melanoma __ __ __ __ ________________________

Psoriasis __ __ __ __ ________________________

Others __ __ __ __ ________________________

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