MEDICAL HISTORY



MEDICAL HISTORY

|Name | |Date of Birth | |Age | |

|Occupation/Job Title | |

|HEIGHT | |PRESENT WEIGHT | | | |

The following information is necessary to help your doctor make important decisions regarding your medical care. Please answer the questions thoroughly.

|CHIEF COMPLAINT (Explain why you are here to see the doctor) |

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|MEDICAL HISTORY Do you have (or have you had): (Explain in the space available) |

|yes |no | |yes |

|Other (Not mentioned above) | |

|PREVIOUS SURGERIES NONE |

|(Check all that apply; indicate the year of the surgery) |

| Cosmetic (Please list) | |

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| Ear | Thyroid |

| Tonsils | Gallbladder |

| Neck | Appendectomy |

| Nasal | Hemorrhoid |

| Sinus | Colon |

| Eye (Type of surgery) | | Gastric Bypass |

| | Hernia |

| Eyelid | Stomach |

| Breast (Type of surgery) | | Hysterectomy |

| | C-section |

| Back (Type of surgery) | | Heart |

| | Coronary Artery Bypass |

| Joints (Please list which) | | Carotid Bypass |

| | Peripheral Vascular |

|Other (Please list) | |

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|yes |no | |

| | |Have you ever had a problem with anesthesia? |

| |What type of problem? | |

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|PREVIOUS ACCIDENTS/INJURIES | |

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|HOSPITALIZATIONS/EMERGENCY ROOM VISITS (within the last year) | |

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|MEDICATIONS NONE |

|List any current or recent medications. INCLUDE THE DOSAGE. Use the back of this page if necessary. |

|Medicine | |Indications | |Dosage |

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|Do you take any of the following homeopathic products or dietary supplements? |

|yes |no | |

|ALLERGIES NONE |

|List any medication allergies. INCLUDE WHAT HAPPENS TO YOU when you take this medication. |

|Medicine | |Side Effect/Allergic Reaction |

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|SOCIAL HISTORY |

|Occupation: | |How long? | |

|Are you presently single, married, separated, divorced, or widowed? (Circle) |

|Smoking: | |Packs per day. |How many years? | | Never Smoked |

| | Previously smoked up to | |packs per day; date quit | | |

|Alcohol consumption: | |drinks per (day / week / month) of (beer / wine / liquor) (Circle) |

|Do you use, or have you used, any recreational drugs? Yes No (List) | |

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|REVIEW OF SYSTEMS If yes, please indicate if you are currently experiencing any of these symptoms) |

|Constitutional |

|Yes |no | |yes |no | |

| | |In generally good health | | |Fever |

| | |Recent weight change | | |Night sweats |

| | |Chills | | |Chronic fatigue |

|Eyes/Vision |

|yes |no | |yes |no | |

| | |Eye disease or injury | | |Glasses |

| | |Dry eyes | | |Contact lenses |

| | |Blurred/Double vision | | | |

|Ears, Nose, Throat |

|yes |no | |yes |no | |

| | |Hearing loss | | |Nose bleeds |

| | |Ringing in the ears | | |Mouth sores |

| | |Earaches or drainage | | |Voice changes |

| | |Sinus problems | | |Swollen glands in the neck |

|Heart/Cardiovascular |

|yes |no | |yes |no | |

| | |Heart trouble | | |Swelling of feet, ankles, or hands |

| | |Chest pains | | |Heart murmur |

| | |Palpitations | | | |

|Respiratory |

|yes |no | |yes |no | |

| | |Chronic cough | | |Coughing up blood |

| | |Shortness of breath | | |Wheezing |

|Gastrointestinal |

|yes |no | |yes |no | |

| | |Heartburn | | |Constipation |

| | |Nausea or vomiting | | |Blood in the stool |

| | |Stomach pain | | |Changes in bowel habits |

| | |Frequent diarrhea | | | |

|Genitourinary |

|yes |no | |yes |no | |

| | |Frequent urination | | |Painful periods |

| | |Burning or painful urination |First menstrual period | |

| | |Blood in urine |Last menstrual period | |

| | |Incontinence |Number of pregnancies | |

| | |Vaginal discharge |Number of children | |

|Musculoskeletal |

|yes |no | |yes |no | |

| | |Joint pain | | |Muscle pain |

| | |Joint stiffness or swelling | | |Chronic neck pain |

| | |Muscle weakness | | |Chronic back pain |

|Skin And Breasts |

|yes |no | |yes |no | |

| | |Rashes or itching | | |Breast pain |

| | |Palpable lumps or nodules | | |Nipple inversion |

| | |Skin cancer | | |Nipple discharge |

| | |Fibrocystic breast disease |Present bra size: | |

|Date/Result of last mammogram: | |

|Neurologic |

|yes |no | |yes |no | |

| | |Migraine headaches | | |Numbness or tingling sensations |

| | |Dizziness | | |Weakness |

| | |Blackouts | | | |

|Endocrine |

|yes |no | |yes |no | |

| | |Excessive thirst or urination | | |Tremors |

| | |Dry skin | | |Heat or cold intolerance |

|Hematologic/Lymphatic |

|yes |no | |yes |no | |

| | |Easily bruise or bleed | | |Swollen glands |

| | |Blood transfusion | | | |

|Psychiatric |

|yes |no | |yes |no | |

| | |Memory loss | | |Depression |

| | |Nervousness/Anxiety | | |Insomnia |

|Who is your psychiatrist? | |

|Who is your psychologist? | |

|For what condition? | |

|yes |no | |

| | |Have you discussed having surgery with him/her? |

| | |May I discuss your surgery with your psychiatrist/psychologist? |

| | |Does he/she have you on any medications? Which? | |

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|FAMILY HISTORY Is there a family history of any of the following problems? |

|yes |no | |yes |no | |

| | |Ovarian Cancer | | |Diabetes Mellitus |

| | |Colon Cancer | | |Heart Disease |

| | | | | |Bleeding Problems |

| | |Breast Cancer |Who? | |

| | |Age Diagnosed: | |

| | |Other Cancer | |

| | |Other Conditions: (Refer to Page 1) | |

| | |Anesthesia Problems (What type of problem?) | |

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|Parents |

|Mother | Alive | Deceased |Cause of death: | |

|Father | Alive | Deceased |Cause of death: | |

|All of the foregoing is true to the best of my knowledge. |

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|Patient Signature Date |

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