PatientPop
Health History FormPatient’s Name:Date:DOB:MR#Reason for visit: Marital Status ___S___M___W___D Duration of symptoms:Previous treatment, if any:Height:Weight:Pregnancies: Live births: Children:Ongoing and previous medical problems (please circle) : Diabetes High blood pressure Heart disease/MI Asthma High cholesterol Stroke/TIA Sleep Apnea Thyroid disease Acid Reflux Kidney Disease Hepatitis Breast Cancer Skin Cancer Other Cancer_________Other:____________________________________________________________________Surgeries (Please include date and surgeon):Procedure: Date (Mo/yr): Surgeon:_____________________ _______________ _________________________________________________ _______________ _________________________________________________ _______________ _________________________________________________ _______________ _________________________________________________ _______________ ____________________________Medications (Please include over the counter and herbal medications):Medication: Dose/Schedule: Prescribing Doctor/Reason for medication:____________________ ____________ ____________________________________________________ ____________ ____________________________________________________ ____________ ____________________________________________________ ____________ ____________________________________________________ ____________ ________________________________Allergies: Reactions: _____________________ _____________________________________________________________________ ________________________________________________Do you smoke? YES NOHave you ever? YES NOIf YES, how many packs per day?How many years did you smoke?If stopped, when?Alcohol Intake?Recreational Drug Use?Last Mammogram:Last Tetanus Shot:Name: ______________________________Please check the box that corresponds to the frequency of the symptoms listed:CurrentlyPastNever Please explainEye, Hearing problemsFever, chillsMuscle aches, joint painBack painEndocrine/hormonalHeadaches, nerve problemSeizures, strokeHeart murmur, irregular heart beat, palpitationsChest painShortness of breath, breathing problemsUrinary problemsPsychiatric conditionsSkin problemsGastrointestinal complaintsBleeding problemsLeg swellingCancer or tumorHIV/AIDSHepatitisPlease indicate any medical problems in your immediate family (parents, siblings, grandparents) and the person(s) who are being treated for such condition.? Please remember to include those medical conditions of deceased primary relatives and their cause of death. Is there anything else you feel we should know about you? ................
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