Lofts Medical Associates



LOFTS MEDICAL ASSOCIATES

HEALTH HISTORY

|PATIENT INFORMATION |

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|Patient Name: Last _______________________________ First _______________________________ |

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|Sex M F Date of Birth ______/______/________ |

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|Your answers on this form will help your clinician understand your medical concerns and conditions better. If you are |

|uncomfortable with any question, do not answer it. Best estimates are fine if you cannot remember specific details. |

|Thank you! |

|MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs: |

|Medication |Dose |Times per day | |Medication |Dose |Times per day |

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|ALLERGIES or REACTIONS TO MEDICINES/FOODS/OTHER AGENTS: |

|Medication |Reaction or Side Effect |

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|PERSONAL MEDICAL HISTORY |

|Please indicate whether you have had any of the following medical problems (with approximate date of illness or diagnosis): |

|___ Congenital Heart disease: |___ Coagulation (bleeding/clotting) |___ Other problems |

|specify type _____________ |disorder | |

|___ Myocardial Infarction (Heart |___ Cancer (Malignancy) | |

|attack) |specify type _____________ | |

|___ Hypertension (High blood pressure) |___ Depression/suicide attempt | |

|___ Diabetes |___ Alcoholism |___ When was your last Tetanus shot? |

|___ High cholesterol |___ Thyroid problem | |

|___ Stroke |specify type _____________ | |

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|SURGICAL & HOSPITALIZATION HISTORY (Please list all prior operations and dates): |

|Operation |Date | |Hospitalization |Date |

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|SOCIAL HISTORY | |

|Tobacco Use: |Caffeine Use |

|Cigarettes |Do you drink liquids containing caffeine? ___ No ___ Yes |

|___ Quit: Date__________ |Alcohol Use |

|___ Never |Do you drink alcohol? ___ No ___ Yes: # drinks/week_____ |

|___ Current: Smoker: packs/day____ # of yrs ________ |EXERCISE: |

|Are you interested in quitting? ___ No ___ Yes |Do you exercise regularly? ___ No ___ Yes |

|FAMILY HISTORY |

|Please indicate with a check (√) family members who have had any of the following conditions: |

|Medical Condition |

|Please list your most recent immunizations. Please include your best estimate of the month and year of each immunization. |

|DATE |IMMUNIZATION | |DATE |IMMUNIZATION | |DATE |IMMUNIZATION |

| |Hepatitis B | | |Mumps | | |Varicella shot (Shingles) |

| |Tetanus (Td) | | |Rubella | | |Other: |

| |Tetanus (Tdap) | | |MMR | | | |

|REVIEW OF SYSTEMS |

|Please check (√) any current problems you have on the list below. |

|Constitutional | |Gastrointestinal | |Psychiatric |

|___Fevers/chills/sweats | |___Abdominal pain | |___Anxiety/stress |

|___Unexplained weight loss/gain | |___Blood in bowel movement | |___Problems with sleep |

|___Fatigue/weakness | |___Nausea/vomiting/diarrhea | |___Depression |

|___Excessive thirst or urination | | | | |

|Eyes | |Chest (breast) | |Musculo-skeletal |

|___Change in vision | |___Breast lump/discharge | |___Muscle/joint pain |

|Ears/Nose/Throat/Mouth | |Respiratory | |Blood/Lymphatic |

|___Difficult hearing/ringing in ears | |___Cough/wheeze | |___Unexplained lumps |

|___Problems with teeth/gums | |___Difficulty breathing | |___Easy bruising/bleeding |

|___Hay fever/allergies | | | | |

|Cardiovascular | |Genitourinary | |Neurological |

|___Chest pain/discomfort | |___Nighttime urination | |___Headaches |

|___Leg pain with exercise | |___Leaking urine | |___Dizziness/light-headedness |

|___Palpitations | |___Unusual vaginal bleeding | |___Numbness |

| | |___Discharge: penis or vagina | |___Memory loss |

| | |___Sexual function problems | |___Loss of coordination |

|Skin | |Other (please specify) | | |

|___ Rash or mole change | |____ | | |

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