Review of Systems - Medical History

[Pages:2]

REVIEW OF SYSTEMS / MEDICAL HISTORY

(New Patient Visit)

Name: __________________________________________________________________ Date of Birth: _____/_____/______

Last

First

Middle

History or current problem with any of the following? (Please check all that apply)

Problems with bleeding

Yes No Menstrual Changes

Yes No

Allergy to Adhesive

Problems with healing Problems with scarring (hypertrophic or keloid)

Abdominal Pain

Yes No

Yes No

Yes No

Muscle Weakness Neck Stiffness Night Sweats

Yes No Yes No Yes No

Allergy to Lido c aine Allergy to topic al antibiotic ointments Artificial Heart Valves

Anxiety

Yes No

Rash/Hives

Yes No Artificial Joints in the last 2 yrs

Bloody Stool/Urine

Yes No Seizures

Yes No

Blood Thinners

Blurry Vision

Yes No

Shortness of Breath

Yes No

Defibrillator

Chest Pain

Yes No

Sleeplessness

Yes No

MRSA

Cough Depression Dizziness

Yes No

Yes No

Yes No

Sore Throat

Yes No

Thyroid Problems

Yes No

Unintentional Weight loss Yes No

Pacemaker Currently pregnant or planning a pregnancy Premedication prior to procedures

Fever or Chills Grey Discoloration of Skin Hay Fever

Yes No

Yes No

Yes No

Vaginal Candidiasis Wheezing Red Eye

Yes No

Yes No

Yes No

Rapid heartbeat with epinephrine Transplant HIV

Yes No Yes No Yes No

Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Yes No Yes No Yes No Yes No

Headaches Immunosuppression Joint Aches Joint Replacement

Yes No

Yes No

Yes No Yes No

Tearing

Eye Pain

Elevated Blood Sugar Uncontrolled Blood Pressure

Yes No

Yes No

Yes No

Yes No

Have you had any of the following conditions? (Please check all that apply)

Acne Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Psoriasis Poison Ivy

Actinic Keratosis (pre-skin cancer)

Precancerous Moles Squamous Cell Skin Cancer Basal Cell Skin Cancer Melanoma

Year ________________ Other _________________

Have you ever tested positive for TB?

Do you have any environmental allergies? If yes, please list _____________________________________

Are you allergic to any medications? If yes, please list ______________________________________

Have ever tested positive for hepatitis? If yes, please list which type ______________________________________

Yes No Yes No Yes No Yes No

Hypertension: Have you been diagnosed with high blood pressure/hypertension?

Yes No Do you have a family history of melanoma?

Yes No If yes, which relative(s)?

Vaccinations: Have you received your flu vaccination for the current year?

Yes No

Have you received your pneumonia vaccination?

Yes No

Are you currently taking any of the blood thinners? (Check from listed below)

Aspirin Effient

Cilostazol (Pletal)

Eliquis

Coumadin (Warfarin)

Pentoxyfylline (Trental)

Dipyridamole (Aggrenox)

Plavix (Clipidogrel)

Pradaxa

Ticagrelor (Brilinta)

Ticlodipin (Ticlid) Xarelto

REVIEW OF SYSTEMS / MEDICAL HISTORY

(New Patient Visit)

Date of Birth: _____/_____/______

Medication

Medications

(List All)

Dosage

Frequency

Route

Medical Problems

(Please list any medical problems for which you are regularly treated)

Surgical History

Surgery

Date

Signature: _________________________________________________________________

Date: ________________________

Printed Name: _____________________________________________________________________________________________

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