SOCIAL HISTORY:



HEALTH HISTORY

Patient Name ________________________________________________ DOB ____________________

LIST ALL ALLERGIES (to medications, food or latex)

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LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

(Over the counter drugs, non-prescription drugs and herbal supplements should be included)

|Medication Name |Dosage |Frequency |

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LIST ANY HOSPITALIZATIONS AND/OR SURGERIES YOU HAVE HAD (with dates)

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FAMILY MEDICAL HISTORY

| |

|Last Flu shot _____________________________ |

|Last Pneumonia vaccine _____________________ |

|Last Tetanus booster _____________________ |

|Last TB skin test ____________________ |

|Last Cholesterol level ______________________ |

SOCIAL HISTORY

Do you smoke? ? YES ? NO How many packs per day? _____________ For how many years? ____________

Drink alcoholic beverages? ? YES ? NO Average number per week? ____________

Do you take any street drugs? ? YES ? NO What type? _________________________________

How many caffeinated beverages daily? _______________________ What type? ___________________________________

Do you exercise? ? YES ? NO How frequently? ___________ What type? ___________________________________

Any difficulty with sleep? ? YES ? NO Describe: ______________________________________________________

MEDICAL PROBLEMS YOU HAVE NOW OR HAVE HAD IN PAST

(You may write in anything not specifically listed)

NOW PAST

? ? AIDS / HIV

? ? Allergies / Hay fever

? ? Anemia

? ? Asthma / Wheezing

? ? Arthritis / Rheumatism

? ? Bladder Problems (painful, frequency, loss of control, blood in urine)

? ? Bleeding problems / Bruising

? ? Bronchitis / Chronic Cough

? ? Cancer

? ? Change in Bowel Habits / Constipation / Diarrhea / Blood or Tarry Stools

? ? Chest Pain

? ? Childhood Illness (specify): ___________________________________________________________

? ? Convulsions / Seizures

? ? Depression / Mood Disorders / Mental Illness

? ? Diabetes

? ? Diverticulitis / Crohn’s Disease

? ? Dizziness / Fainting

? ? Ear Problems

? ? Eye Problems / Glaucoma

? ? Foot Problems (pain, numb, or cold feet)

? ? Gall Bladder Disease

? ? Gout

? ? Headaches (frequent or Migraine)

? ? Heart Problems (Murmurs / Mitral Valve) _______________________________________________

? ? Heart Attack / Congestive Heart Failure

? ? Hemorrhoids

? ? Hepatitis / Yellow Jaundice

? ? Hernia

? ? High Blood Pressure

? ? Indigestion / Frequent Heartburn / Hiatal Hernia

? ? Kidney Problems (stones or frequent infections)

? ? Leg problems (pain or difficulty walking, varicose veins)

? ? Lung Problems / COPD / Emphysema

? ? Nose Bleeds

? ? Osteoporosis

? ? Pneumonia

? ? Prostate Disease

? ? Sinus Problems

? ? Skin Disorders – Acne / Psoriasis / Eczema / Rashes

? ? Stomach Ulcer

? ? Stroke / TIA

? ? Thyroid Disease

? ? Weight (recent unexplained loss or gain)

Other illnesses or additional details

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FEMALE PATIENTS ONLY

Are you pregnant? ? YES ? NO

Number of pregnancies: _______ Miscarriages: _______ Abortions: _______ Live Births: ________

Date of last menstrual cycle: __________ Usual length of cycle: __________ Days of flow: __________

Usual menstrual cycle: ? Regular ? Irregular ? Painful/Cramps

Birth Control Method: _____________________________________________________________________

If menopausal, do you experience any symptoms? ? YES ? NO

Date of last PAP test: ______________________________________________ ? Normal ? Abnormal

Date and Facility of last Mammogram: ________________________________ ? Normal ? Abnormal

How often do you perform Self Breast Exams? _________________________________________________

MALE PATIENTS ONLY

Any urinary complaints? (hesitation in starting urine stream, decrease in force or flow, dribbling)

How many times per night do you awaken to urinate? ___________________________________________

Any difficulty in getting or maintaining an erection? ? YES ? NO

Date of last prostate exam: _________________________________________________________________

Have you had a PSA blood test? ? YES ? NO

Date of PSA: ____________________________________________________ ? Normal ? Abnormal

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