Name: Sex: M /F Date of birth:
CONFIDENTIAL HEALTH HISTORYName: Sex: M /F Date of birth: Height: Weight: _______ Dr.: ____ Babkes / ____ Courtney / ____ Reaven Reason for visit: Symptom (current)Location (part of body)Onset (when it started)Severity (from 1-10)Allergies: No known drug allergiesOR: aspirin Penicillin Sulfa contrast dye Other (please list): Past Medical History: (please check all that apply and list others)NeurologicalEndocrineRenal/G.U.Infectionsbrain aneurysmthyroid disorderincontinenceHIV/AIDSbrain tumordiabetesbladder dysfunctiontuberculosisdementiaChildhood Illnesskidney stonesHSVheadachespolioENTMusculoskeletalhead injuryrheumatic feverhearing lossarthritismemory problemsmeningitisMeniere'sspine diseasemuscle disordersDermatologicinfectionsbone cancermultiple sclerosisrashglaucomainjuriesneuropathyshinglesvertigoPsychiatricstroke/TIAmelanomaHematologicdepressionParkinson'sGastrointestinalanemiabipolar disorderseizure disorderliver problemscanceranxietyCardiovascularbowel problemsclotting problemspanic attacksheart diseasecancerInflammatoryOtherhigh blood pressureIBDsarcoidosisheart murmurIBSlupusirregular heartbeatulcerspolymyalgiaPast surgical history: (please check all that apply and list others)Spinal surgeryCancer surgeryCarotid endarterectomyTransplantCABGBrain surgeryPacemakerOtherSocial history: (please check all that apply)Tobacco useAlcohol useCaffeine useIllegal drug useFamily history: (please check all that apply and list others for parents, siblings, children):Abnormal movementsHereditary muscle/nerve diseaseParkinson's diseaseSeizure disorderMigraine/headachesDementiaMultiple sclerosisOtherReview of Systems: (please circle all current symptoms)NeurologicalGeneralMusculoskeletalEyesCardiovascularSkinweakness/paralysisfeverneck painabrupt vision losschest painrashnumbnesschillsback painblurred visionleg paindrynessdifficulty speakingweight changejoint paindouble visionelevated blood pressureGastrointestinalgait/balance difficultynight sweatsjoint swellingeye painheart murmurabdominal painheadachesENTmuscle crampsvisual spotsirregular heartbeatconstipationdizzinessdifficulty swallowingmuscle painPsychiatricG.U.diarrheaseizureshearing lossEndocrinedepressionchanges in libidoappetite changeinvoluntary movements/tremorringing in earscold intoleranceanxietysexual dysfunctionImmunologicforgetfulnessPulmonaryheat intolerancepanic attacksurinary frequencyrecent asthma attackfaintingshortness of breathexcessive thirstdisorientationincontinenceallergiessleep problemscoughhair losssuicidal thoughtsurinary retentionOtherdaytime drowsinesssnoringMedication list: (include vitamins and supplements, attach list with additional medications)NameDose (mg)Frequency (times per day)NameDose (mg)Frequency (times per day)Patient Signature: Date: ................
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