Kidney and Urinary - Klamath Pulmonary



365760-275590Patient History Form David Panossian, M.D., P.C.- FACP, FCCP, DABSM Pulmonary and Critical Care Medicine, 2614 Almond Street, Klamath Falls, OR 97601 (541) 885-2201, FAX (541) 883-140000Patient History Form David Panossian, M.D., P.C.- FACP, FCCP, DABSM Pulmonary and Critical Care Medicine, 2614 Almond Street, Klamath Falls, OR 97601 (541) 885-2201, FAX (541) 883-1400 Name: _____________________________________DOB: ______________ Date: __________________What is the major reason for today’s visit? ___________________________________________________Personal HistoryBirthplace_________________________________Race ________________________________Marital Status______________________________Occupations ________________Disabled_______Street Drugs_______________________________Recreation/Hobbies_________________________Exercise___________How Often______________Pets _____________________________________Alcohol ________________Tobacco ____How Long___ Packs Per Day___Tea, Soda, Coffee___________Traveling outside the country ____When__________Exposure to Toxic Chemicals (Radiation, Chemo, Asbestos, Other) _____________________________Medical HistoryHave you had any of the following? Circle those which apply and give dates where appropriate.Measles/MumpsHay fever/sinusitisWhooping Cough PolioScarlet feverDiphtheriaMeningitisInfectious MonoValley FeverTuberculosisExposure to TBSkin test positive to TBMalariaHives PneumoniaBronchitisPleurisy AsthmaEmphysemaRheumatic FeverArthritis Back TroubleCancer Type_____________Venereal diseaseGlaucomaHigh blood pressureCOPDHeart diseaseOSAHeart attack/StrokeAsthma-Age___Diabetes JuvenileEmphysemaDiabetes adult onsetChronic BronchitisNarcolepsyPulmonary FibrosisSeizureLung CancerAnemiaCystic FibrosisBleeding TendencyBlood transfusionHepatitis (yellow jaundice)Nose bleedsHemorrhoids UlcerBladder infectionsKidney diseaseSurgical HistoryHave you had any of the following operations? Circle those which apply and give dates where appropriate. Heart/Cath/Stent/Pacemaker Coronary bypass surgeryHeart valve replacementTonsilsAppendixGall bladderStomach BreastUterus and /or ovaryProstateHerniaThyroidVaricose VeinsHemorrhoidsOther ____________________________________Injury HistoryHave you had any of the following injuries? Circle those which apply and give dates where appropriate.HeadChestAbdomenBroken BonesBackOther ____________________________________AllergiesHave you had allergies to any of the following? Circle or complete which applyTetanus antitoxinPenicillinSulfaOther drugs _______________________________FoodsOther ____________________________________ImmunizationsHave you had the following immunizations? Circle those which apply and give dates where appropriate.SmallpoxTetanusPolioFlu shotPneumovaxOther____________________________________Family HistoryDo you have a family history of any of the following medical conditions? Circle those which apply and list relationship.AnemiaCOPDBleeding TendencyOSALeukemiaAsthmaRepeated infectionsPulmonary FibrosisCrippling infectionsCystic FibrosisHeart diseaseLung CancerChronic lung diseaseEmphysemaTuberculosis Chronic BronchitisHigh blood pressureNarcolepsyKidney disease DiabetesAsthmaSevere allergies Mental illness GoutConvulsions ObesityMigraine headaches Thyroid troublePeptic ulcer Chronic diarrheaCancerFather ? Alive ? Deceased Age ______ Causes of death _________________________ Mother ? Alive ? Deceased Age ______ Causes of death _________________________Systems ReviewHave you recently had the following? GeneralYesNoTire easily FORMCHECKBOX FORMCHECKBOX Weakness FORMCHECKBOX FORMCHECKBOX Night sweats FORMCHECKBOX FORMCHECKBOX Persistent fever FORMCHECKBOX FORMCHECKBOX Sensitivity to heat FORMCHECKBOX FORMCHECKBOX Sensitivity to cold FORMCHECKBOX FORMCHECKBOX Weight Loss FORMCHECKBOX FORMCHECKBOX Weight Gain FORMCHECKBOX FORMCHECKBOX SkinRash FORMCHECKBOX FORMCHECKBOX Change in color FORMCHECKBOX FORMCHECKBOX Change in hair FORMCHECKBOX FORMCHECKBOX Change in nails FORMCHECKBOX FORMCHECKBOX EyesYesNoTrouble seeing FORMCHECKBOX FORMCHECKBOX Eye pain FORMCHECKBOX FORMCHECKBOX Inflamed eyes FORMCHECKBOX FORMCHECKBOX Double vision FORMCHECKBOX FORMCHECKBOX Worn glasses FORMCHECKBOX FORMCHECKBOX EarsLoss of hearing FORMCHECKBOX FORMCHECKBOX Ringing in ears FORMCHECKBOX FORMCHECKBOX Discharge from ears FORMCHECKBOX FORMCHECKBOX NoseLoss of smell FORMCHECKBOX FORMCHECKBOX Frequent colds FORMCHECKBOX FORMCHECKBOX Obstruction FORMCHECKBOX FORMCHECKBOX Excess discharge FORMCHECKBOX FORMCHECKBOX Nosebleeds FORMCHECKBOX FORMCHECKBOX Mouth Sore gums FORMCHECKBOX FORMCHECKBOX Soreness of tongue FORMCHECKBOX FORMCHECKBOX Dental problems FORMCHECKBOX FORMCHECKBOX ThroatPostnasal drainage FORMCHECKBOX FORMCHECKBOX Soreness FORMCHECKBOX FORMCHECKBOX Hoarseness FORMCHECKBOX FORMCHECKBOX Change in voice FORMCHECKBOX FORMCHECKBOX BreastsLumps FORMCHECKBOX FORMCHECKBOX Discharge FORMCHECKBOX FORMCHECKBOX HeartChest pain FORMCHECKBOX FORMCHECKBOX Palpitations FORMCHECKBOX FORMCHECKBOX Short of breath while lying FORMCHECKBOX FORMCHECKBOX High blood pressure FORMCHECKBOX FORMCHECKBOX Vein problems FORMCHECKBOX FORMCHECKBOX LungsCough FORMCHECKBOX FORMCHECKBOX Sputum (phlegm) FORMCHECKBOX FORMCHECKBOX Bloody sputum FORMCHECKBOX FORMCHECKBOX Wheezing FORMCHECKBOX FORMCHECKBOX Pain on breathing in chest FORMCHECKBOX FORMCHECKBOX Shortness of breath FORMCHECKBOX FORMCHECKBOX SOB with exertion FORMCHECKBOX FORMCHECKBOX Swelling in ankles FORMCHECKBOX FORMCHECKBOX Bluish fingers or lips FORMCHECKBOX FORMCHECKBOX AbdomenYesNoChange in appetite FORMCHECKBOX FORMCHECKBOX Difficulty in swallowing FORMCHECKBOX FORMCHECKBOX Heartburn FORMCHECKBOX FORMCHECKBOX Belching FORMCHECKBOX FORMCHECKBOX Excess gas FORMCHECKBOX FORMCHECKBOX Enlargement FORMCHECKBOX FORMCHECKBOX Nausea/Vomiting FORMCHECKBOX FORMCHECKBOX Vomiting blood FORMCHECKBOX FORMCHECKBOX Rectal bleeding FORMCHECKBOX FORMCHECKBOX Bloody stools FORMCHECKBOX FORMCHECKBOX Dark urine FORMCHECKBOX FORMCHECKBOX Jaundice FORMCHECKBOX FORMCHECKBOX Constipation FORMCHECKBOX FORMCHECKBOX Diarrhea FORMCHECKBOX FORMCHECKBOX Hemorrhoids FORMCHECKBOX FORMCHECKBOX Need for laxatives FORMCHECKBOX FORMCHECKBOX Kidney and Urinary Increase in urination at night FORMCHECKBOX FORMCHECKBOX Unable to hold urine FORMCHECKBOX FORMCHECKBOX Impotence FORMCHECKBOX FORMCHECKBOX Lack of sex drive FORMCHECKBOX FORMCHECKBOX Pain with intercourse FORMCHECKBOX FORMCHECKBOX EndocrineThyroid nodule or mass FORMCHECKBOX FORMCHECKBOX High thyroid level FORMCHECKBOX FORMCHECKBOX Low thyroid level FORMCHECKBOX FORMCHECKBOX Adrenal trouble FORMCHECKBOX FORMCHECKBOX High blood sugars FORMCHECKBOX FORMCHECKBOX Low blood sugars FORMCHECKBOX FORMCHECKBOX MuscularMuscle cramps FORMCHECKBOX FORMCHECKBOX Muscle weakness FORMCHECKBOX FORMCHECKBOX Pain in joints FORMCHECKBOX FORMCHECKBOX Swollen joints FORMCHECKBOX FORMCHECKBOX Joint stiffness FORMCHECKBOX FORMCHECKBOX Deformity of joints FORMCHECKBOX FORMCHECKBOX Nervous SystemHeadaches FORMCHECKBOX FORMCHECKBOX Dizziness FORMCHECKBOX FORMCHECKBOX Fainting FORMCHECKBOX FORMCHECKBOX Convulsions or seizures FORMCHECKBOX FORMCHECKBOX Nervousness FORMCHECKBOX FORMCHECKBOX Depression FORMCHECKBOX FORMCHECKBOX Change in sensation FORMCHECKBOX FORMCHECKBOX Memory loss FORMCHECKBOX FORMCHECKBOX Poor coordination FORMCHECKBOX FORMCHECKBOX Weakness FORMCHECKBOX FORMCHECKBOX Paralysis FORMCHECKBOX FORMCHECKBOX Sleep DisordersYesNoSnoring FORMCHECKBOX FORMCHECKBOX Excessive daytime sleepiness FORMCHECKBOX FORMCHECKBOX Pauses in breathing during sleep FORMCHECKBOX FORMCHECKBOX Insomnia FORMCHECKBOX FORMCHECKBOX Sleeplessness FORMCHECKBOX FORMCHECKBOX Sleepiness while driving FORMCHECKBOX FORMCHECKBOX Gyn-OB Pregnant_________ ................
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