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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