History & Physical Form for - Dr. Kristin Egan
|Patient Name: _____________________________________ Date:_____________________________ |
|ALLERGIES to medications, and the REACTION or side effect you get from it: |
|____________________________________________________________________________________________________________________________________________________|
|__________________________________________________________________________________________________________ |
|SOCIAL HISTORY |
|Marital status: Single≤ Married ≤ Widowed≤ Divorced ≤ |
|Occupation (Or prior occupation) _____________________________________________Retired?: ≤ |
|Race/Ethnicity:________________________________________ |
|Do you exercise regularly? Yes ≤ No≤ |
|SUBSTANCES: Check (√) whether current or past use of the following substances. |
|Substance |Never |Current |Past |Amount per day |
|Caffeine | | | | |
|Tobacco | | | | |
|Alcohol | | | | |
|Street Drugs | | | | |
|PATIENT MEDICAL HISTORY |
|Do you now, or have you ever had, the following conditions? |
|≤ Heart Disease |≤ Polio |
|≤ Hypertension |≤ Cancer |
|≤ Heart Attack or Stroke |≤ Headaches |
|≤ High cholesterol |≤ Blood Transfusions |
|≤ Measles or Mumps |≤ Surgery (please list) |
|≤ Meningitis |__________________________________________________________________________|
|≤ Hepatitis |__________________________________________________________________________|
|≤ Rheumatic Fever |________________ |
|≤ Scarlet Fever | |
|FAMILY MEDICAL HISTORY |
|Does anyone in your family have the following? Specify relationship and age at time of problem. |
|High Blood Pressure Yes ≤ No≤ Ear/Nose/Throat Yes ≤ No≤ |
|Heart problems Yes ≤ No≤ Diabetes Yes ≤ No≤ |
|Kidney problems Yes ≤ No≤ Stroke Yes ≤ No≤ |
|Blood clots in legs or lungs Yes ≤ No≤ Cancer Yes ≤ No≤ Type:_________ |
|Bleeding/clotting disorders Yes ≤ No≤ Other______________________________________ |
|Is your mother alive? Yes ≤ No≤ |
|Is your father alive? Yes ≤ No≤ |
|MEDICATIONS you are currently using |
|_______________________________________________________________________________________________________________________________________________________|
|_______________________________________________________________________________________________________________________________________________________|
|__________________________________________________ |
|_______________________________________________________________________________________________________________________________________________________|
|_________________________ |
| |
| |
|WHY ARE YOU HERE TODAY? |
|_______________________________________________________________________________________________________________________________________________________|
|___________________ |
|OTHER CURRENT MEDICAL PROBLEMS? |
|_______________________________________________________________________________________________________________________________________________________|
|________________________________________________________________________________________________________ |
|SYMPTOMS |
|Circle any persistent symptoms you currently have or have had in the PAST YEAR. |
|ENT |GASTROINTESTINAL |HEMILYPH |
|Pain or discharge (running) from your ears |Vomit blood or have black tarry stools |Bruise or bleed easily |
|Bothersome cough |Severe stomach pains |Become tired or exhausted easily |
|Hay fever or constantly stuffed up nose |Frequent periods of belching, heartburn, vomiting, |Anemic |
|Nosebleeds |indigestion, diarrhea |Problems with your blood |
|Ringing in your ears | |Sickle cell anemia |
| |GENITOURINARY |Have you ever had syphilis or any venereal |
|EYE |Pain or burning on urination or trouble starting your |disease? |
|Pain in your eyes or see rainbows (halos) around|stream | |
|lights |Urinate more frequently than usual or get up at to urinate|NEUROPSYCHIATRIC |
|Complete or partial blindness or seeing double |Have you ever had kidney or bladder problems |Feeling dizzy |
|Glaucoma (hardening of the eyeball)? | |Difficulty with your balance |
| |MUSCULOSKELETAL |Had fits, seizures, or convulsions |
|CARDIOVASCULAR |Swollen or painful joints |Periods of unconsciousness |
|High blood pressure |Neck, back, or leg pain |Loss of strength or feeling constant numbness|
|Swelling in your ankles or feet | |in any part of your body |
|Chest pain |ENDOCRINE |Nervous breakdown |
|Wake up at night out of breath |Diabetes |Wanted to see a doctor because of |
|Difficulty breathing after climbing one flight |Sugar in your urine of blood |nervousness, Depression, or emotional |
|of stairs |Have you ever had goiter in your neck Thyroid disease |problems? |
| | | |
|RESPIRATORY |WOMEN ONLY | |
|Trouble breathing |Have you experienced menopause? | |
|Coughed up blood | | |
|Asthma or wheezing | | |
|Tuberculosis (TB) | | |
|Abnormal chest x-ray? | | |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- nyc physical form for school
- physical form for school ny
- blank physical form for employment
- basic physical form for employment
- nys physical form for school
- standard physical form for employment
- florida physical form for school
- physical form for school nyc
- ct physical form for school
- general physical form for children
- illinois physical form for employment
- physical form for employment pdf