HEALTH HISTORY - heart surgeons
HEALTH HISTORY
Patient Name____________________________________________Today’s Date__________________
Date of Birth_____________________Age_______Height________________Weight______________
|Symptoms Check (() symptoms you currently have or have had in the past year. |
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|GENERAL |GASTROINTESTINAL |EYE, EAR, NOSE, THROAT |MEN ONLY |
|□ Chills |□ Appetite poor |□ Bleeding gums |□ Breast lump |
|□ Depression |□ Bloating |□ Blurred vision |□ Erection difficulties |
|□ Dizziness |□ Bowel changes |□ Crossed eyes |□ Lump in testicles |
|□ Fainting |□ Constipation |□ Difficulty swallowing |□ Penis discharge |
|□ Fever |□ Diarrhea |□ Double vision |□ Sore on penis |
|□ Forgetfulness |□ Excessive hunger |□ Earache |□ Other |
|□ Headache |□ Excessive thirst |□ Ear discharge |WOMEN ONLY |
|□ Loss of sleep |□ Gas |□ Hay fever |□ Abnormal Pap Smear |
|□ Loss of weight |□ Hemorrhoids |□ Hoarseness |□ Bleeding between periods |
|□ Nervousness |□ Indigestion |□ Loss of hearing |□ Breast lump |
|□ Numbness |□ Nausea |□ Nosebleeds |□ Extreme menstrual pain |
|□ Sweats |□ Rectal bleeding |□ Persistent cough |□ Hot flashes |
|MUSCLE/JOINT/BONE |□ Stomach pain |□ Ringing in ears |□ Nipple discharge |
|Pain, weakness, numbness: |□ Vomiting |□ Sinus problems |□ Painful intercourse |
|□ Arms □ Hips |□ Vomiting blood |□ Vision - Flashes |□ Vaginal discharge |
|□ Back □ Legs |CARDIOVASCULAR |□ Vision – Halos |□ Other |
|□ Feet □ Neck |□ Chest pain |SKIN | |
|□ Hands □ Shoulders |□ High blood pressure |□ Bruise easily |Date of last menstrual |
|GENITO-URINARY |□ Irregular heart beat |□ Hives |period_____________ |
|□ Blood in urine |□ Low blood pressure |□ Itching | |
|□ Frequent urination |□ Poor circulation |□ Change in moles |Are you pregnant?___ |
|□ Lack of bladder control |□ Rapid heart beat |□ Rash | |
|□ Painful urination |□ Swelling of ankles |□ Scars |# of children?_______ |
| |□ Varicose veins |□ Sore that won’t heal | |
|Conditions Check (() conditions you have or have had in the past. |
|□ AIDS |□ Chemical Dependency |□ High Cholesterol |□ Prostate Problem |
|□ Alcoholism |□ Chicken Pox |□ HIV Positive |□ Psychiatric Care |
|□ Anemia |□ Diabetes |□ Kidney Disease |□ Rheumatic Fever |
|□ Anorexia |□ Emphysema |□ Liver Disease |□ Scarlet Fever |
|□ Appendicitis |□ Epilepsy |□ Measles |□ Stroke |
|□ Arthritis |□ Glaucoma |□ Migraine Headaches |□ Suicide Attempt |
|□ Asthma |□ Goiter |□ Miscarriage |□ Thyroid Problems |
|□ Bleeding Disorders |□ Gonorrhea |□ Mononucleosis |□ Tonsillitis |
|□ Breast Lump |□ Gout |□ Multiple Sclerosis |□ Tuberculosis |
|□ Bronchitis |□ Heart Disease |□ Mumps |□ Typhoid Fever |
|□ Bulimia |□ Hepatitis |□ Pacemaker |□ Ulcers |
|□ Cancer |□ Hernia |□ Pneumonia |□ Vaginal Infections |
|□ Cataracts |□ Herpes |□ Polio |□ Venereal Disease |
|Current Medications |
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HEALTH HISTORY
|Allergies (to medications or substances) |
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|Family History |
|Family history of premature heart disease? □ Yes □ No ( If yes, explain below) |
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|Hospitalizations |
|Year |Hospital |Reason for Hospital and Outcome |
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|Serious Illness/Injuries |Date |Outcome |
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|Health Habits Check (() which substances you use and describe how much you use. |
| |Tobacco | |
| |Street Drugs | |
| |Alcohol |How much per week? |
|Occupational Concerns Check (() if your work exposes you to the following: |
| |Stress |
| |Hazardous Substances |
| |Heavy Lifting |
| |Other |
|Your occupation (if retired, please list former occupation): |
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