Name:______________________________
1. Since your last visit, have any other physicians diagnosed you with any new illnesses?
No ___
Yes ___ . If yes, what illness(s) has/have been diagnosed?
2. Since your last visit, have you been prescribed any new medications or have you, yourself, begun any new medications (including vitamins, minerals, supplements, etc.)?
No ___
Yes ___ . If yes, what are these medications (including doses)
3. Since your last visit, have you visited the Emergency Department for any reason?
No ___
Yes ___ . If yes, when, where and why?
4. Since your last visit, have you received any vaccinations?
No ___
Yes ___ . Which one(s)?
5. Have you had any tests ordered by another physician?
No ___
Yes ___ . Which ones?
6. Have you developed any new allergies?
No ___
Yes ___ . To what?
7. Has your family history (i.e., blood relatives) changed since your last visit? ___ Yes ___ No
If yes, in what way (relative and diagnosis)?
8. Do you smoke? ___ Yes ___ No.
9. Do you drink alcohol? ___Yes ___ No. If yes, do you
Feel you should cut down? ___ Yes ___ No
Get annoyed at others telling you that you should cut down or quit? ___ Yes ___ No
Feel guilty about drinking? ___ Yes ___ No
Need an “eye opener” in the morning? ___ Yes ___ No
10. Do you have a working smoke alarm? ___Yes ___ No.
11. If you have gas heat, do you have a carbon monoxide detector? ___ Yes ___ No
12. Do you wear your seat belt at all times? ___ Yes ___No.
13. Are you troubled by any of the following?
___ Marital problems
___ Recent separation or divorce
___ Death of a family member or close friend
___ Unemployment
___ Spiritual problems
14. Review of systems - please check any symptoms that you currently are experiencing
A. Skin
__ Rash __ New skin growths __ A sore that does not heal
__ Hives __ Yellowing of the skin __ Bruising easily
__ Dry skin __ Night sweats __ Mole(s) that have changed
B. Eyes
__ Cloudy vision __ Seeing spots or floaters __ Double vision
__ Eye pain __ Dry or scratchy eyes __ Yellowing of the eyes
C. Ears, nose and throat
__ Hearing loss __ Drainage from the ears __ Ear pain
__ Ringing in ears __ Sinus problems __ Post nasal drip
__ Nose bleeds __ Loss of sense of smell __ Snoring
__ Hoarseness __ Problems swallowing __ Tooth or gum pain
__ Mouth ulcers __ Sore throat
D. Lungs
__ Wheezing __ Pain on breathing __ Chronic cough
__ Coughing blood __ Coughing up phlegm __ Shortness of breath
__ Having to use multiple pillows to help you breath
E. Heart
__ Chest pain or tightness __ Rapid heart beat __ Fainting
__ Dizziness __ Irregular heart beat __ Swollen ankles
__ Leg cramps while walking __ Getting up at night short of breath
__ Getting up at night to urinate
F. Stomach and intestines
__ Heartburn/indigestion __ Trouble swallowing __ Abdominal pain
__ Constipation __ Diarrhea __ Excessive gas
__ Black, tarry stools __ Increased hunger
__ Frequent upset stomach or vomiting
__ Burning abdominal pain between meals or which awakens you at night
__ Weight loss in the last six months
__ Weight gain in the last six months
__ Change in bowel habits or caliber of the stool
__ Blood in bowel movements or on toilet tissue
G. Kidney and bladder
__ Burning after urination __ Dribbling after urination __ Trouble starting urination
__ Loss of control of the urine __ Blood in the urine
__ Increased thirst __ Feeling of not completely emptying
H. Muscles, bones and joints
__ Joint pain __ Joint stiffness __ Red or swollen joints
__ Back or neck pain __ Bone pain __ Muscle weakness
__ Locking of a joint
I. Nervous system
__ Headaches __ Loss of eyesight __ Change or loss of speech
__ Weakness in an arm or leg __ Dizzy __ Problems with balance
__ Anxiety __ Nervousness __ Depression __ Confusion
__ Numbness of the face, arm or leg
J. Men Only
__ Discharge from the penis __ Problems getting or keeping an erection
__ Loss of sexual desire __ Pain during sex
__ Pain or swelling in the testicles __ Lump in a testicle
K. Women Only
__ Lump in a breast __ Abnormal vaginal bleeding __ Irregular periods
__ Cessation of periods __ Discharge from the vagina __ Pain during sex
__ Leaking of urine when coughing, sneezing, laughing, etc
__ Do you examine your breasts regularly? ___ Yes ___ No
When was your last menstrual period?
15. Please list all of your medications and their dosages -
16. Is there anything that you wish to discuss today, at this visit? ___ Yes ___ No
Specifically, what?
Thank you very much.
LVPG Internal Medicine
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