Patient History Worksheet Patient's Name: Date of Birth ...

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Patient History Worksheet

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CURRENT MEDICATIONS: None

Drug Name / Strength

Example Drug Name 10mg

Patient History Worksheet

Dose

2 capsules

Frequency

Twice Daily

Prescribed By

Dr. Example

MEDICATION ALLERGIES: None Ace Inhibitors Acetaminophen (Tylenol) Amoxicillin Aspirin Caine's (lidocaine, etc) Cephalosporins Codeine Demerol Erythromycin Lorcet

MARITAL STATUS: Divorced Engaged Married Separated Single Widowed

SOCIAL HISTORY: Disabled Employed

Occupation: _____________________

Homemaker Not Presently Employed Retired Self Employed Student

Patient's Name - Please Print

Signature of Patient or Parent of Minor

PHW Page(2/2)

Lortab Morphine NSAIDS Oxycontin Penicillin Percocet Percodan Phenytoin Sulfa Tetracycline

ALCOHOL HISTORY: Current Every Day Current Some Days Former Never

TOBACCO HISTORY: *REQUIRED IF 13 OR OLDER Current Every Day

Packs/Day: __________ Current Some Days

Packs/Day: __________ Former Never Chewing Tobacco

Patient's Date of Birth

Tylox Vicodin

Allergy to Poultry / Eggs

Non-Medication Allergies:

DOMINANT HAND: Ambidextrous Left Handed Right Handed

FAMILY HISTORY: None Provided Adopted: Unknown Family History Anemia Anesthesia Difficulties Arthritis Bleeding Disorders Cancer Congenital Anomoly Diabetes Heart Disease, unspecified Osteoarthritis Osteoporosis Rheumatoid Arthritis Stroke

Revised 7-28-12 RGB

REVIEW OF SYSTEMS

Please indicate personal history within the last month or associated with today's complaint.

CONSTITUTIONAL: Weight loss Weight gain Fever Fatigue Pregnant

EYES: Wears glasses or contacts

HENT: Headaches Dentures Dental problems Gingival bleeding

CARDIOVASCULAR: Chest pain Irregular heart beats Shortness of breath walking Swelling of hands/feet

RESPIRATORY: Abnormal sputum production Shortness of breath Wheezing Cough

GASTROINTESTINAL: Loss of appetite Nausea Vomiting Diarrhea Constipation Blood in stool Abdominal pain

No Yes No Yes No Yes No Yes No Yes

No Yes

No Yes No Yes No Yes No Yes

No Yes No Yes No Yes No Yes

No Yes No Yes No Yes No Yes

No Yes No Yes No Yes No Yes No Yes No Yes No Yes

GENITOURINARY: Frequency (urination) Dysuria (painful urnination) Hematuria (blood in urine) Incontinence

INTEGUMENT: Rash Itching Pigmentation changes

NEUROLOGIC: Tingling and numbness Tremors Paralysis Light headed/dizzy

MUSCULOSKELETAL: Joint pain Joint swelling Muscular weakness Muscle pain Back pain Limitation of motion

PSYCHIATRIC: Memory loss Anxiety Depression Difficulty sleeping

HEME-LYMPH: Easy bleeding Easy Bruising Cuts slow to heal Anemia

No Yes No Yes No Yes No Yes

No Yes No Yes No Yes

No Yes No Yes No Yes No Yes

No Yes No Yes No Yes No Yes No Yes No Yes

No Yes No Yes No Yes No Yes

No Yes No Yes No Yes No Yes

To the best of my knowledge, the questions on this form have been answered accurately. I understand that providing incorrect information can be dangerous to my health. It is my responisbility to inform the doctor of any changes in my medical status. I also authorize the medical staff to perform the necessary services I may need.

Patient's Name - Please Print Date ROS Page(1/1)

Signature of Patient or Parent of Minor

Patient Date of Birth

Revised 7.28.12 RGB

 ................
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