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? | | |

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