ANNE COLEMAN, M



Anne Coleman, M.D., P.A.

Patient History

(Please Print)

|Name | |____ | |Age | |Date | |

You may make additional comments or attach separate sheets where needed. Please be sure to write your name at the top of EACH page.

|What are the main reasons for your visit to our office? |

|1. |

|2. |

|3. |

|How or why did you select our office to address your concerns? |

|REVIEW OF SYSTEMS Please complete the following by placing aαby any symptom that you have experienced in the past year. |

|1. General/Constitutional |8. Genitourinary |

|ο Weight Loss |ο Weight Gain |

|ο Blurred Vision |ο Crossed Eyes |

|ο Bleeding Gums |ο Earache |

|ο Tightness |ο Lump in Throat |

|ο Chest Pain |ο Palpitations |ο Poor Circulation |ο Swollen Ankles |

| 6. Respiratory |ο Excess Hunger |ο Excess Thirst | | |

|ο Shortness of Breath |ο Wheezing |14. Heme/Lymphatic | |

| 7. Gastrointestinal |ο Easy Bleeding |ο Swollen Lymph Nodes | |

|ο Bloating/Gas |ο Bowel Changes |ο Constipation |ο Diarrhea |15. Allergic/Immune |

|ο Hemorrhoids |ο Rectal Bleeding |ο Nausea/Vomiting |ο Vomiting Blood |

List names and specialties of all physician seen in the last year.

* * * * *

Name _____ Date Page 2

|Men Only |

|ο Erection Difficulties |ο Lump in Testicles |ο Penis Discharge |ο Sore on Penis |Number of Children |

|Female Only |

|ο Bleeding Between Periods |ο Breast Lump |ο Severe Menstrual Pain |ο Hot Flashes |ο Night Sweats |

| |ο Nipple Discharge |ο Painful Intercourse |ο Vaginal Discharge | |

|Date of Last Period |Date of Last PAP Smear ο Normal ο |Date of Last Mammogram |

| |Abnormal | |

|Pregnant? ο Yes ο No ο Maybe |Number of Pregnancies |Number of Terminations |

|Number of Children |Any Complications? |Fertility Treatments? |

MEDICAL HISTORY Please complete the following by placing aαby any illness that applies and the year of onset or diagnosis.

|ο AIDS/HIV Positive |ο CODP |ο Liver Disease |

|ο Alcoholism |ο Diabetes |ο Migraine Headache |

|ο Anorexia |ο Depression |ο Miscarriage |

|ο Appendicitis |ο Arthritis |ο Mononucleosis |

|ο Arrthymia / Irregular Heartbeat |ο Emphysema |ο Multiple Sclerosis |

|ο Arthritis |ο Endocrine / Glandular Disease |ο Osteoporosis |

|ο Asthma | Specify Above: |ο Pacemaker Date Inserted: |

|ο Bleeding Disorders |ο Epilepsy |ο Pneumonia |

|ο Blood Transfusion |ο Fibromyalgia |ο Polio |

|ο Breast Lump |ο Thyroid Goiter |ο Prostate Problem |

|ο Bronchitis |ο Gonorrhea |ο Rheumatic / Scarlet Fever |

|ο Bulimia |ο Gout |ο Stroke |

|ο Cancer (specify below) |ο Heart Disease / Murmur |ο Suicide Attempt |

| Type: |ο Hepatitis |ο Thyroid Problems |

|ο Candidiasis |ο Hernia |ο Tonsillitis |

|ο Cataracts |ο Herpes |ο Tuberculosis |

|ο Chemical Dependency |ο High Cholesterol |ο Ulcers |

|ο Claudication |ο High Blood Pressure |ο Urinary Tract / Bladder Infections |

|ο Congestive Heart Failure |ο Kidney Disease |ο Vaginal Infections |

Additional Comments or Illnesses Not Mentioned

SURGICAL HISTORY Please list hospitalizations or surgeries with dates below.

|Date |Hospitalization or Surgical Procedure |Date |Hospitalization or Surgical Procedure |

| | | | |

| | | | |

| | | | |

| | | | |

|Do you have a will? ο Yes ο No |

* * * * *

Name _____ Date Page 3 ALLERGIES Please list below.

|Medication Allergies |Other Allergies |

| | |

| | |

| | |

INTERVENTIONS / DISEASE SCREENS Please aαby any that apply and the year of most recent.

|ο Tetanus Booster |ο Flex Sig |ο Cholesterol Test |ο Flu Shot |

|ο Colonoscopy |ο Sonogram |ο ECG |ο Upper GI |

|ο MRI / CT Scan |ο Stool Test for Blood |ο Mammogram |ο Complete Lab Work |

LIFESTYLE Please answer questions below.

|Tobacco (If you have never used tobacco, skip to alcohol section below) |

|1. Types? |

|2. How often / how much? |

|3. How many years? |

|4. Interested in quitting? What have you tried? |

|Alcohol (If you have never used alcohol, skip to caffeine section below) |

|1. How often / how much? |

|2. How many years? |

|3. Ever feel it’s a problem? |

|4. Ever drink and drive? |

|Caffeine (If you never use caffeine, skip this question) |

|1. How many servings per day? |

|2. What types of caffeine drinks? |

|3. Other types of caffeine? |

SOCIAL HISTORY Please answer questions below.

|Marital Status |

|What is your highest level of education? |

|Do you exercise? How often and what types of exercise? |

|How would you describe your diet? (Please check all that apply) |

|ο Well balanced |ο No vegetables |ο Too much fat |ο Too much sugar |ο Too little fiber |ο Too much salt |ο Fast food |

|How would you describe your sleep habits? |

|ο Difficulty falling asleep |ο Trouble staying asleep |ο Light Sleeper |ο Snoring |

|ο Apnea (Stop breathing) |ο Early morning awakening |ο Daytime drowsiness |ο Take medications for sleep |

FAMILY HISTORY Please list significant illnesses such as heart disease, cancer, hypertension, etc.

|Mother | |

|Maternal Grandmother | |

|Maternal Grandfather | |

|Father | |

|Paternal Grandmother | |

|Paternal Grandfather | |

|Siblings | |

|Other Relatives | |

* * * * *

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