Atlantic Highlands Internal Medicine



Atlantic Highlands Internal Medicine

1012 State Route 36 Atlantic Highlands, NJ 07716

(732) 291-3865 FAX: (732) 291-3859

DATE: ____________________ COMPLETE MEDICAL HISTORY FORM

NAME: ______________________________ AGE: _____ DATE OF BIRTH: _______

I. CHIEF COMPLAINT: Main reason for your visit today? Please list anything you would like to discuss with the doctor:

________________________________________________________________________________________________________________________________________________

II. PAST MEDICAL HISTORY

A. Surgeries:

T & A (tonsils) Date: _________________ Hysterectomy Date: ___________________

Appendectomy Date: ______________________ Ovaries removed? Yes No (circle)

Cholecystectomy (gallbladder) Date: _____________________

Was hysterectomy done to treat a cancer? Yes No (circle)

Other surgeries and dates: __________________________________________________

Biopsies done: what kind and dates: __________________________________________

B. Hospitalizations: (other than for surgeries)

Date: _____________ Where: ___________________ Reason? ___________________

________________________________________________________________________________________________________________________________________________

C. Injuries/Fractures (type, date and how injured):

________________________________________________________________________________________________________________________________________________

D. Present Medications (prescription and over-the-counter):

Name Dose # Taken Daily Reason

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Herbs and Supplements: ___________________________________________________

E. Allergies: Yes or NO (circle one)

Medications: What type of Reaction:

________________________________________________________________________________________________________________________________________________

Other Substances, Foods, etc:

________________________________________________________________________________________________________________________________________________

F. Immunizations: Check Childhood Shots Given:

DPT ____ Mumps ____ Measles ____ Rubella ____ Polio ____ Smallpox ____

Tetanus Booster Date: _______________

Pneumovax (pneumonia vaccine) Date: _______________

Influenza (date of last shot) Date: _______________

Hepatitis B (series of 3 shots) Date: _______________

Others: Date: _______________

________________________________________________________________________________________________________________________________________________

III. FAMILY HISTORY

Mother: Age (if living) _______ Age (at death) _______ Cause of death _____________

List any medical problems she has had:

________________________________________________________________________________________________________________________________________________

Father: Age (if living) _______ Age (at death) _______ Cause of death _____________

List any medical problems she has had:

________________________________________________________________________________________________________________________________________________

Brother(s): Ages and any medical problems he/they have had:______________________

________________________________________________________________________

Sister(s): Ages and any medical problems she/they have had: ______________________

________________________________________________________________________

Any other blood relatives with:

Relationship Relationship

Diabetes ____________________ High Blood Pressure __________________

Heart Attack _________________ Breast Cancer ________________________

Stroke ______________________ Colon Cancer ________________________

Tuberculosis _________________ High Cholesterol _____________________

Alzheimer’s __________________ Melanoma (skin cancer) ________________

Prostate Cancer _______________ Ovarian Cancer ______________________

IV. LIFESTYLE HISTORY

A. Marital Status:

Single  Married  Divorced 

Significant Other (male)  Significant other (female) 

B. Have you ever been pregnant? Yes  No  N/A 

If yes, how many pregnancies? __________ How many births/children? _____________

C. Smoker? currently  ex-smoker  nonsmoker  chewing tobacco 

If a smoker, number of packs (pipes, cigars) per day: _____________________________

How long have you smoked?__________ If ex-smoker, when did you quit? ___________

D. Alcohol intake:

What do you usually drink? _____________ how much? _______ how often? _________

 Do not drink alcohol

E. Exercise:

Do you exercise regularly? _____________ What activity? ________________________

How often?______________________ How long is each session? __________________

F. Diet: Check any foods you avoid in your diet:

 salt  sugar  fats (oils)  red meat  eggs  poultry  wheat  caffeine

 other _________________________________________________________________

G. Usual # of meals per day: ______ # of times per week you eat “fast foods” ________

H. Travel: Have you recently traveled outside the U.S.? ____________

Where did you go? ________________________________________________________________________

I. Work:

Occupation: _______________Work related illnesses or injuries? __________________

Injury/Illness while employed as:

____________________________ _______________________________________________________________________

____________________________ _______________________________________________________________________

Do you have a history of exposure to toxic chemicals or substances? Yes  No 

What Where When

________________________ ________________________ __________________________

________________________ ________________________ __________________________

V. HEALTH MAINTENANCE

A. Date of last physical/annual exam________ Examiner _________________________

B. Date of last Pap smear ___________________________________________________

C. Date of last Cholesterol level _____________________________________________

D. Date of last EKG _______________________________________________________

E. Date of last Chest X-ray _________________________________________________

F. Date of last Prostate exam ________________________________________________

G. Date of last complete blood test ___________________________________________

H. Date of last Thyroid level ________________________________________________

I. Date of last Sigmoidoscopy or Colonoscopy __________________________________

J. Date of last Bone Density _________________________________________________

K. Date of last mammogram ________________________________________________

VI. REVIEW OF SYSTEMS

A. In the past, have you been diagnosed as having any of the following conditions? Check and date:

| High Blood Pressure | | Varicose Veins | |

| Hardening of the Arteries | | Phlebitis (blood clots) | |

| Heart Attack | | Headaches (migraine, cluster, or tension) | |

| Stroke or “TIA” | | High Cholesterol or Triglycerides | |

| Heart Murmur | | Sexual Dysfunction | |

| Angina | | Congestive Heart Failure | |

| Cataracts | | Glaucoma | |

| Sinusitis | | Menieres Disease | |

| Nasal Polyps | | Allergic Rhinitis | |

| Tonsillitis | | Gum Disease | |

| Cervical (neck) Strain | | Arthritis | |

| Lupus | | Rheumatoid Arthritis | |

| Emphysema | | Chronic Bronchitis | |

| Pneumonia | | Asthma | |

| Fibrocystic Breast Disease | | Galactorrhea (breast discharge) | |

| Hyperthyroidism (over-active thyroid) | | Hypothyroidism (low thyroid) | |

| Pernicious Anemia | | Lymphoma | |

| Peptic Ulcer (gastric or duodenal) | | Iron Deficiency Anemia | |

| Gastritis / Esophagitis | | Diabetes | |

| Intestinal Polyps | | Malabsorption | |

| Diverticulosis | | Diverticulitis | |

| Irritable Bowel (spastic colon) | | Chronic Fatigue Syndrome | |

| Reflux or GERD | | Enlarged Prostate | |

| Fibromyalgia | | Crohn’s Colitis | |

| Ulcerative Colitis | | Prostatitis (prostate infection) | |

| Hemorrhoids | | Pelvic Inflammatory Disease | |

| Epididymitis | | Uterine Fibroids | |

| Cancer (any kind) | | Cystitis (bladder infection) | |

| Vaginitis | | Hepatitis A, B, or C | |

| Pyelonephritis (kidney infection) | | Panic Attacks | |

| Kidney Stone | | Gallstones | |

| Hypoglycemia | | PMS or PMDD or Dysmenorrhea | |

| Bulimia or Anorexia | | Depression | |

| Abnormal pap smear | | Multiple Sclerosis | |

| Abnormal x-ray finding | | Neurologic Disease | |

B. Presently or in the recent past, have you had any of the following symptoms?:

| Recurrent Headaches | | Weight Loss # of pounds lost | |

| Fever (unexplained) | | Chills | |

| Generalized Fatigue | | Generalized Weakness | |

| Double Vision | | Ringing in ears | |

| Recurrent sinus infection | | Recurrent sore throats | |

| Hoarseness | | Neck Stiffness | |

| Coughing up blood | | Chronic Cough | |

| Chest Pressure/Tightness on exertion | | Chest Pressure/Tightness at rest | |

| Feeling dizzy or off-balance | | Pain in legs while walking | |

| Change in appetite | | Abdominal burning pain | |

| Nausea | | Diarrhea | |

| Change in bowel habits | | Rectal Bleeding | |

| Painful urination | | Change in urinary habits | |

| Breast Pain | | Weight Gain # of pounds gained | |

| Night Sweats | | Generalized Body Aches | |

| Change in vision | | Change in hearing | |

| Frequent nosebleeds | | Recurrent gum or tooth infections | |

| Constant sinus drainage | | Trouble swallowing | |

| Swollen glands | | Shortness of breath on exertion | |

| Shortness of breath laying down | | Coughing up phlegm in morning | |

| Feeling faint or almost passing out | | Swollen ankles or feet | |

| Heartburn or indigestion | | Abdominal cramping pain | |

| Vomiting | | Constipation | |

| Blood in urine or stool | | Frequent or urgent urination | |

| Head injury and loss of consciousness | | Vaginal discharge or odor | |

| Change in menstrual periods | | Change in sexual desire | |

| Breast lump | | Nipple discharge | |

| Testicular pain | | Skin rash | |

| Easy bruising or bleeding | | Changes in hair | |

| Trouble sleeping | | Depression | |

| Muscle weakness or pain | | Tingling in hands or feet | |

| Joint swelling or joint pain | | Testicular swelling | |

| Changes in skin or moles | | Lumps in neck, underarms, or groin | |

| Sensation of being too hot or cold | | Nervousness, panic | |

| Mood swings | | Numbness | |

| Memory loss | | Seizures or convulsions | |

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