Lofts Medical Associates
LOFTS MEDICAL ASSOCIATES
HEALTH HISTORY
|PATIENT INFORMATION |
| |
|Patient Name: Last _______________________________ First _______________________________ |
| |
|Sex M F Date of Birth ______/______/________ |
| |
|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 |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
|ALLERGIES or REACTIONS TO MEDICINES/FOODS/OTHER AGENTS: |
|Medication |Reaction or Side Effect |
| | |
| | |
| | |
| | |
|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 _____________ | |
| | | |
|SURGICAL & HOSPITALIZATION HISTORY (Please list all prior operations and dates): |
|Operation |Date | |Hospitalization |Date |
| | | | | |
| | | | | |
| | | | | |
|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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