MEDICAL HISTORY & REVIEW OF SYSTEMS: Please check all …



MEDICAL HISTORY & REVIEW OF SYMPTOMS:

Do you currently have or have you had in the past any problems related to the following systems?

(Please check all that apply)

|Past Surgeries |Social History |Family History |

|□ Tonsillectomy | | |

|□ Heart bypass |Do you smoke? □Yes □ No |Is your mother living? □Yes □ No |

|□ Hysterectomy |# packs/day ______________________ |List medical problems/cause of death |

|□ Knee replacement |Former Smoker? □Yes □ No |_______________________________ |

|□ Appendectomy |Year Quit smoking ________________ |_______________________________ |

|□ Gall Bladder |How soon after you wake up do you smoke your first | |

|□ Hip replacement |cigarette? ________________ |Is your father living? □Yes □ No |

|□ Rotator cuff repair |Are you interested in quitting? □Yes □ No |List medical problems/cause of death |

|□ Spine surgery | |_______________________________ |

|□ ___________________________ |Do you drink alcohol? □Yes □ No |_______________________________ |

|□ ___________________________ |How much per day? _______________ | |

| |_________________________________ | |

|Skin |Endocrine/Hematologic/Immunologic |Musculoskeletal |

|□ itching/dryness |□ anemia |□ Arthritis |

|□ bruising |□ excessive thirst |□ Joint Stiffness |

|□ breast disease |□ appetite change |□ Fibromyalgia |

|□ rashes |□ Diabetes |□ Joint Swelling |

| |□ easy bleeding/bleeding disorder |□ Joint Pain |

|□ None of the above/negative |□ blood transfusion | |

| |□ Cold Intolerance |□ None of the above |

|General/Constitutional |□ Frequent urination | |

|□ Chills |□ Heat Intolerance | |

|□ Significant weight gain |□ Osteopenia |Psychological |

|□ Cancer |□ Osteoporosis |□ ADHD □ Anxiety |

|□ Night Sweats |□ Thyroid Problems |□ Bipolar Disorder □ Depression |

|□ Weight loss | |□ Nervousness □ OCD |

|□ Fatigue |□ None of the above/negative | |

|□ Fever | |□ None of the above/negative |

|□ None of the above/negative | | |

|Genitourinary |Eyes, ears, nose and throat |Respiratory |

|□ Stool Incontinence |□ Double vision |□ Frequent or chronic cough |

|□ Urinary tract Infections |□ Glaucoma |□ Shortness of breath |

|□ Urinary Incontinence |□ Sore throats |□ Tuberculosis |

|□ Kidney Stones |□ Poor hearing |□ Lung Disease |

|□ Bloody stools |□ Glasses/contacts |□ Coughing up Phlegm |

|□ Prostate disorder |□ Frequent nose bleeds |□ COPD |

| |□ Hearing aide __ R __ L __ Both |□ Asthma |

|□ None of the above/negative | |□ Coughing up blood |

| |□ Hoarseness |□ Wheezing |

| |□ Sinus Infections |□ None of the above/negative |

| |□ None of the above/negative | |

|Cardiovascular |Neurologic |Gastrointestinal |

|□ Breathlessness |□ Speech difficulties |□ Reflux |

|□ Heart attack |□ Stroke |□ Abdominal pain |

|□ Edema/Swelling hands |□ Numbness |□ Bloody Stool |

|□ Heart murmur |□ Seizures |□ Nausea |

|□ Phlebitis |□ Tingling |□ Hemorrhoids |

|□ Chest pain or angina |□ Dizziness |□ Vomiting |

|□ Peripheral vascular disease |□ Paralysis |□ Vomiting Blood |

|□ Palpitations |□ Migraine Headaches |□ Diarrhea |

|□ Blood clots |□ Lyme Disease |□ Constipation |

|□ Arrhythmia/irregular heart beat | |□ Ulcers |

|□ Pacemaker/Defibrillator |□ None of the above/negative |□ Heartburn |

|□ High Blood Pressure | |□ Hepatitis |

|□ High Cholesterol | |□ Gall Stones |

|□ Heart Problems | |□ IBS |

|□ None of the above/negative | |□ None of the above/negative |

Print Name: _________________________________________________________________ Date: __________________________

Please list your Medications: (Name of drug, dosage, frequency and *administration. i.e. by mouth, injection, topical, sublingual, etc.)

MEDICATION: DOSAGE: FREQUENCY: *ADMINISTRATION:

_________________________________ __________________ ___________________ __________________________

_________________________________ __________________ ___________________ __________________________

_________________________________ __________________ ___________________ __________________________

_________________________________ __________________ ___________________ __________________________

_________________________________ __________________ ___________________ __________________________

_________________________________ __________________ ___________________ __________________________

_________________________________ __________________ ___________________ __________________________

_________________________________ __________________ ___________________ __________________________

_________________________________ __________________ ___________________ __________________________

_________________________________ __________________ ___________________ __________________________

|Allergies |Infectious Disease |Fall Risk Screening |

| | | |

|Drug Allergies: ___________________ |□ MRSA □ C-Diff |Please select one of the following related to the |

|________________________________ |□ Tuberculosis □ Other:___________ |number of falls you had within the last year: |

|________________________________ |_________________________________ |□ No falls |

|________________________________ |_________________________________ |□ One fall with injury |

|________________________________ |_________________________________ |□ Two or more falls with injury |

| | |□ One fall without injury |

|Latex Allergy? Y / N |□ None of the above/negative |□ Two or more falls without injury |

| | | |

|Vitals |Advance Directive |Work Status |

| | | |

|Height: __________ Weight: _________ |Please check on of the following: |Occupation: __________________ |

| |□ Do Not Resuscitate | |

| |□ Non Surrogate Decision Maker |□ Sedentary □ Heavy labor |

| |□ Surrogate Decision Maker |□ Retired □ Disabled |

| |□ Patient Prefers not to Answer | |

Use the diagram and pain scale below to specify what symptoms you are experiencing and where they are located as well as the level of pain today. Use the corresponding numbers to indicate the types of sensations you are experiencing in those locations. [pic] [pic]

Patient Signature: ________________________________ Print Name: ____________________________ Date:______________

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