MDVIP Physical Update Form - Piedmont



Name: ___________________________Date of Birth: _________________________DETAILED PATIENT INFORMATIONPlease list any medical problems/ diseases that you have:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please list all medications, herbs, vitamins and over-the-counter products you are taking:NameDose/StrengthHow often you take itName: ___________________________Date of Birth: _________________________Please list all allergies to medications, foods, chemicals, plants and the reactions you have:AllergyReactionFAMILY HISTORYPlease list all family members including mother, father, sisters, and brothers: Check here if adoptedFamily memberNameMedical ProblemsAgeDeceasedAny diseases/illnesses that run in the family (Cancer, Diabetes, Heart Disease, etc):______________________________________________________________________________________________________________________________________________________________________________________________________Name: ___________________________Date of Birth: _________________________SURGICAL HISTORYPlease list all surgeries or procedures you have had done:DateType of Surgery/ProcedureReason for ProcedureHospitalName of SurgeonPlease list all medical specialists that you see:Name of DoctorSpecialtyName: ___________________________Date of Birth: _________________________SOCIAL HISTORYName: _________________________Date of Birth: _______________________Birthplace: ______________________Level of education completed: __________What you do for work: ____________________________________________________Marital StatusCurrent status: Divorced Married Single WidowedDo you live alone: Yes NoPreviously widowed: Yes NoPreviously divorced: Yes NoChildren Yes NoNumber of sons: ________________Number of daughters: ___________________TobaccoAre you a smoker: Yes No FormerPassive smoker exposure: Yes NoType: _______________________Packs/day ___________________________Years smoked: ______Year Quit: _____Ever tried to quit: Yes NoCaffeineDo you drink caffeine: Yes NoType: Chocolate Coffee Soda Tablets TeaAlcoholDo you drink alcohol: Yes No Formerly Year Quit: ________Type: Beer Hard Liquor WineFrequency: ____________Amount: ___________Last drink: _______________LifestyleActivity level: Sedentary Moderate VigorousHealth club member: Now Previously NeverType of exercise: __________________________________________________________Exercise Frequency: _______________________Hours/week: ___________________Hobbies/Activities: ________________________________________________________Specific type of diet: Low fat Low carb Diabetic Weight watchersAnimals in the home Yes NoType: __________________________Are you the one who cleans up after the animal: Yes NoName: ___________________________Date of Birth: _________________________Recent TravelAny recent travel out of the state Yes NoWhere: ________________________Any recent travel out of the country Yes NoWhere: ________________________SafetyAre there smoke detectors in the home? Yes NoAre there carbon monoxide detectors in the home? Yes NoIs there radon in the home? Yes NoDo you have firearms in the home? Yes NoDo you wear a seatbelt? Yes NoAdvanced Directives in PlaceMark the advanced directives that you currently have in place: None DNR Living Will Durable Power of Attorney HC ProxyDo you agree to a transfusion? Yes NoName: ___________________________Date of Birth: _________________________HEALTH MAINTENANCEPlease fill in the date of your most recent health maintenance event (if applicable):EventDate of LastColonoscopy/ GI procedureStress test/ Cardiac procedureEchocardiogramEye examSkin examMammogram/ Breast examPap-smearPSA/ Prostate examRectal exam/ Stool cards/ FOBTBone DensityVaccine/ ImmunizationDate of LastTetanus (Td)Pneumonia vaccineFlu vaccineHepatitis A vaccineHepatitis B vaccineTB/ PPD (Tuberculosis screening)MMR (Measles, Mumps & Rubella)ZostavaxInfectious Disease HistoryDo you have any history of blood/ blood product transfusion? If so, when and for what reason? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________Name: ___________________________Date of Birth: _________________________Do you have any history of tick bites, Lyme disease, Rocky Mountain Spotted Fever, or Ehrlichiosis? If so, please explain:___________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you ever had a positive PPD test (Tuberculosis screening)? If so, what happened as a result of that positive test?___________________________________________________________________________________________________________________________________________________________________________________________________________________________Any concern for possible HIV infection? If so, please explain:___________________________________________________________________________________________________________________________________________________________________________________________________________________________Gynecological History (Females)Number of PregnanciesNumber of Premature BirthsNumber of C-SectionsNumber of Vaginal BirthsNumber of Life BirthsNumber of Births at TermNumber of Children Currently LivingNumber of Ectopic PregnanciesNumber of MiscarriagesNumber of Abortions Check here if currently pregnant Name: ___________________________Date of Birth: _________________________REVIEW OF SYSTEMS Have you experienced any of the following symptoms in the past month?Activity changeNo YesChillsNoYesDecreased appetiteNoYesFatigueNoYesFeverNoYesInsomniaNoYesIrritabilityNoYesMalaise/ feeling unwellNoYesNight sweatsNoYesAbnormal palenessNoYesWeaknessNoYesWeight gainNoYesWeight lossNoYes CONSTITUTIONAL HEENT continued…Radical keratotomyNo YesLasikNoYesLast eye examEar dischargeNoYesCerumen/ ear waxNoYesEar fullnessNoYesHearing lossNoYesNoise exposureNoYesEar painNoYesTinnitus/ ringing in the earsNoYesVertigo/ dizzinessNoYes Decreased smellNo YesNasal discharge/ drainageNoYesNose bleedsNoYesFacial painNoYesInfectionsNoYesNasal congestionNoYesSneezingNoYes HEENT NOSE AND SINUSHeadacheNo YesEye burningNoYesDouble visionNoYesEye discharge/ drainageNoYesEye drynessNoYesForeign body sensationNoYesEye itchingNoYesRapid eye movementsNoYesEye painNoYesSensitivity to lightNoYesEye rednessNoYesVisual halloes or blind spotsNoYesSpots/ floatersNoYesTearingNo YesGlassesNoYesContactsNoYesVisual LossNoYesName: ___________________________Date of Birth: _________________________Cramping in legs when walkingNoYesBlueing of the hands/ feetNoYesFlushing or redness of hands/ feetNoYesCool extremitiesNoYesSwelling of hands, feet or legsNoYesPain in extremitiesNoYesUlcers in legs, feet and armsNoYesVaricose veinsNoYesBlood clotsNoYesTHROAT AND MOUTHVASCULARTaste changeNoYesVoice changeNoYesCold soresNoYesDifficulty swallowingNoYesHoarsenessNoYesLump sensationNoYesPain when swallowingNoYesPost nasal dripNoYesSore tongue/ tongue lesionsNoYesSore throatNoYesTooth pain/ dentures/ platesNoYes Abdominal mass/ growthNoYesAbdominal painNoYesAltered bowel habits- change from normalNoYesNot eating or poor appetiteNoYesBlack, tarry stoolsNoYesBloating and feeling of fullnessNoYesBlood in stoolNoYesConstipationNoYesDiarrheaNoYesDifficult or painful swallowingNoYesRESPIRATORY/ THORAXGASTROINTESTINALRapid breathingNoYesCoughNoYesChest painNoYesFrequent respiratory infectionsNoYesCoughing up bloodNoYesKnown TB exposureNoYesPositive PPD/ TB testNoYesPain with breathing “stitch”NoYesShortness of breathNoYesWheezingNoYesFlatulence/ gasNoYesJaundice/ yellow/ history of hepatitisNoYesIndigestion/ heartburn NoYesThrowing up bloodNoYesNauseaNoYesWeight lossNoYesHemorrhoidsNoYesRectal bleedingNoYesReflux NoYesVomitingNoYesCARDIOVASCULARChest painNoYesShortness of breath at restNoYesShortness of breath on exertionNoYesSleep sitting up to breatheNoYesShortness of breath at night- causes awakeningNoYesSwelling of hands and legsNoYesNighttime urinationNoYesPalpitations/ rapid heart beatNoYesPassing outNoYesName: ___________________________Date of Birth: _________________________GENITOURINARY WOMEN TO COMPLETE Back pain/ flank/ side painNoYesChange in urine color/ cloudy urineNoYesUrgency to urinateNoYesDecreased stream or low urine outputNoYesPain when urinatingNoYesFoul urine odorNoYesUrinating frequentlyNoYesMass in groinNoYesBlood in urineNoYesHesitancy or difficulty urinatingNoYesUrine leakage/ incontinenceNoYesAge of first periodLast menstrual periodFrequency of menstrual cyclesAre you post-menopausal?NoYesAre you on hormones?NoYesHave you previously used hormones?NoYesHave you ever used birth control?NoYesHave you ever had an abnormal pap?NoYesDo you do self breast exams?NoYesLack of libidoNoYesNipple dischargeNoYesBreast lumpsNoYesPain with sexual intercourseNoYesHistory of uterine fibroidsNoYesProblems with infertilityNoYesOvarian cystsNoYesSexual dysfunctionNoYesVaginal itchingNoYesVaginal dischargeNoYesHistory of passing a kidney stoneNoYesUrgency to urinateNoYesMETABOLIC/ ENDOCRINEVoice changesNoYesCold intolerance/ feeling coldNoYesHeat intolerance/ feeling hotNoYesHair lossNoYesCoarse hairNoYesAbnormal glucose/blood sugar testsNoYesAbnormal fat distributionNoYesAbnormal hair distributionNoYesChronically overweightNoYesChronically underweightNoYesDarkening of skinNoYesHistory of goutNoYesExcessive perspirationNo YesExcessive hunger or thirstNoYesGeneralized weaknessNoYesGestational diabetesNoYesGoiterNoYesGynecomastia/ male breast enlargementNoYesLow sugar reactionsNoYesIncrease in size of feet/ handsNoYesAre you circumcised?NoYeserectile painNoYesPenile dischargeNoYesBlood in your streamNoYesScrotum/ testicular painNoYesScrotum/ testicular massNoYesHydrocele/ fluid around testesNoYesHistory of Herpes GenitaliaNoYesProblems with fertilityNoYesHave you ever been treated for a sexually transmitted disease?NoYesDescribe your sexual function Normal Decreased MEN TO COMPLETEName: ___________________________Date of Birth: _________________________NEURO/ PSYCHIATRIC MUSCULOSKELETALLanguage disorder/ Difficulty talkingNo YesUnclear pronunciationNoYesFocal weaknessNoYesDifficulty walkingNoYesHeadachesNoYesIncontinenceNoYesIn-coordinationNoYesLightheadedness/ dizzinessNoYesLoss of consciousness/ faintingNoYesMemory lossNoYesTingling/ numbnessNoYesSeizuresNoYesSpeech changesNoYesTremorsNoYesVertigo/ Hx of Meniere’sNoYesVisual changesNoYesLack of concentrationNoYesDo you have any anxiety?NoYesDo you feel fearful?NoYesDo you feel excessively happy?NoYesDo you feel paranoid?NoYesBack pain- neck, mid, low backNoYesBone/ joint swelling or painNoYesHands/ wrist/ elbow shoulder/ hips/ feet/ ankle swelling or painNoYesMuscle pain/ weaknessNoYes HEMATOLOGICEasy bruisingNoYesEasy bleedingNoYesHistory of blood clotsNoYesAnemia or low blood countNoYesSwollen lymph nodesNoYesAsthmaNoYesHay feverNoYesHivesNoYesAnaphylaxisNoYesContact dermatitis/ rashes/ metal allergyNoYesFood allergiesNoYes“Bee” sting allergyNoYes If yes, reaction type:Environmental allergies: pollen, pollutionNoYesAnimals at homeNoYesAnimals in the work placeNoYesChemicals in the homeNoYes If yes, type:Chemicals in the work placeNoYes If yes, type:IMMUNOLOGICDERMATOLOGICAcneNo YesContact allergiesNoYesHx of excessive sun exposureNoYesFrequent skin infectionsNoYesHair lossNoYesWomen: facial hairNoYesNail changes (brittle)NoYesChange in skin colorNoYesSevere itchingNoYesExcessive sweatingNoYesSensitivity to lightNoYesRashNoYesSkin lesions: tags, moles, freckles, birthmarksNoYes ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download