Atlantic Highlands Internal Medicine
Atlantic Highlands Internal Medicine
1012 State Route 36 Atlantic Highlands, NJ 07716
(732) 291-3865 FAX: (732) 291-3859
DATE: ____________________ COMPLETE MEDICAL HISTORY FORM
NAME: ______________________________ AGE: _____ DATE OF BIRTH: _______
I. CHIEF COMPLAINT: Main reason for your visit today? Please list anything you would like to discuss with the doctor:
________________________________________________________________________________________________________________________________________________
II. PAST MEDICAL HISTORY
A. Surgeries:
T & A (tonsils) Date: _________________ Hysterectomy Date: ___________________
Appendectomy Date: ______________________ Ovaries removed? Yes No (circle)
Cholecystectomy (gallbladder) Date: _____________________
Was hysterectomy done to treat a cancer? Yes No (circle)
Other surgeries and dates: __________________________________________________
Biopsies done: what kind and dates: __________________________________________
B. Hospitalizations: (other than for surgeries)
Date: _____________ Where: ___________________ Reason? ___________________
________________________________________________________________________________________________________________________________________________
C. Injuries/Fractures (type, date and how injured):
________________________________________________________________________________________________________________________________________________
D. Present Medications (prescription and over-the-counter):
Name Dose # Taken Daily Reason
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Herbs and Supplements: ___________________________________________________
E. Allergies: Yes or NO (circle one)
Medications: What type of Reaction:
________________________________________________________________________________________________________________________________________________
Other Substances, Foods, etc:
________________________________________________________________________________________________________________________________________________
F. Immunizations: Check Childhood Shots Given:
DPT ____ Mumps ____ Measles ____ Rubella ____ Polio ____ Smallpox ____
Tetanus Booster Date: _______________
Pneumovax (pneumonia vaccine) Date: _______________
Influenza (date of last shot) Date: _______________
Hepatitis B (series of 3 shots) Date: _______________
Others: Date: _______________
________________________________________________________________________________________________________________________________________________
III. FAMILY HISTORY
Mother: Age (if living) _______ Age (at death) _______ Cause of death _____________
List any medical problems she has had:
________________________________________________________________________________________________________________________________________________
Father: Age (if living) _______ Age (at death) _______ Cause of death _____________
List any medical problems she has had:
________________________________________________________________________________________________________________________________________________
Brother(s): Ages and any medical problems he/they have had:______________________
________________________________________________________________________
Sister(s): Ages and any medical problems she/they have had: ______________________
________________________________________________________________________
Any other blood relatives with:
Relationship Relationship
Diabetes ____________________ High Blood Pressure __________________
Heart Attack _________________ Breast Cancer ________________________
Stroke ______________________ Colon Cancer ________________________
Tuberculosis _________________ High Cholesterol _____________________
Alzheimer’s __________________ Melanoma (skin cancer) ________________
Prostate Cancer _______________ Ovarian Cancer ______________________
IV. LIFESTYLE HISTORY
A. Marital Status:
Single Married Divorced
Significant Other (male) Significant other (female)
B. Have you ever been pregnant? Yes No N/A
If yes, how many pregnancies? __________ How many births/children? _____________
C. Smoker? currently ex-smoker nonsmoker chewing tobacco
If a smoker, number of packs (pipes, cigars) per day: _____________________________
How long have you smoked?__________ If ex-smoker, when did you quit? ___________
D. Alcohol intake:
What do you usually drink? _____________ how much? _______ how often? _________
Do not drink alcohol
E. Exercise:
Do you exercise regularly? _____________ What activity? ________________________
How often?______________________ How long is each session? __________________
F. Diet: Check any foods you avoid in your diet:
salt sugar fats (oils) red meat eggs poultry wheat caffeine
other _________________________________________________________________
G. Usual # of meals per day: ______ # of times per week you eat “fast foods” ________
H. Travel: Have you recently traveled outside the U.S.? ____________
Where did you go? ________________________________________________________________________
I. Work:
Occupation: _______________Work related illnesses or injuries? __________________
Injury/Illness while employed as:
____________________________ _______________________________________________________________________
____________________________ _______________________________________________________________________
Do you have a history of exposure to toxic chemicals or substances? Yes No
What Where When
________________________ ________________________ __________________________
________________________ ________________________ __________________________
V. HEALTH MAINTENANCE
A. Date of last physical/annual exam________ Examiner _________________________
B. Date of last Pap smear ___________________________________________________
C. Date of last Cholesterol level _____________________________________________
D. Date of last EKG _______________________________________________________
E. Date of last Chest X-ray _________________________________________________
F. Date of last Prostate exam ________________________________________________
G. Date of last complete blood test ___________________________________________
H. Date of last Thyroid level ________________________________________________
I. Date of last Sigmoidoscopy or Colonoscopy __________________________________
J. Date of last Bone Density _________________________________________________
K. Date of last mammogram ________________________________________________
VI. REVIEW OF SYSTEMS
A. In the past, have you been diagnosed as having any of the following conditions? Check and date:
| High Blood Pressure | | Varicose Veins | |
| Hardening of the Arteries | | Phlebitis (blood clots) | |
| Heart Attack | | Headaches (migraine, cluster, or tension) | |
| Stroke or “TIA” | | High Cholesterol or Triglycerides | |
| Heart Murmur | | Sexual Dysfunction | |
| Angina | | Congestive Heart Failure | |
| Cataracts | | Glaucoma | |
| Sinusitis | | Menieres Disease | |
| Nasal Polyps | | Allergic Rhinitis | |
| Tonsillitis | | Gum Disease | |
| Cervical (neck) Strain | | Arthritis | |
| Lupus | | Rheumatoid Arthritis | |
| Emphysema | | Chronic Bronchitis | |
| Pneumonia | | Asthma | |
| Fibrocystic Breast Disease | | Galactorrhea (breast discharge) | |
| Hyperthyroidism (over-active thyroid) | | Hypothyroidism (low thyroid) | |
| Pernicious Anemia | | Lymphoma | |
| Peptic Ulcer (gastric or duodenal) | | Iron Deficiency Anemia | |
| Gastritis / Esophagitis | | Diabetes | |
| Intestinal Polyps | | Malabsorption | |
| Diverticulosis | | Diverticulitis | |
| Irritable Bowel (spastic colon) | | Chronic Fatigue Syndrome | |
| Reflux or GERD | | Enlarged Prostate | |
| Fibromyalgia | | Crohn’s Colitis | |
| Ulcerative Colitis | | Prostatitis (prostate infection) | |
| Hemorrhoids | | Pelvic Inflammatory Disease | |
| Epididymitis | | Uterine Fibroids | |
| Cancer (any kind) | | Cystitis (bladder infection) | |
| Vaginitis | | Hepatitis A, B, or C | |
| Pyelonephritis (kidney infection) | | Panic Attacks | |
| Kidney Stone | | Gallstones | |
| Hypoglycemia | | PMS or PMDD or Dysmenorrhea | |
| Bulimia or Anorexia | | Depression | |
| Abnormal pap smear | | Multiple Sclerosis | |
| Abnormal x-ray finding | | Neurologic Disease | |
B. Presently or in the recent past, have you had any of the following symptoms?:
| Recurrent Headaches | | Weight Loss # of pounds lost | |
| Fever (unexplained) | | Chills | |
| Generalized Fatigue | | Generalized Weakness | |
| Double Vision | | Ringing in ears | |
| Recurrent sinus infection | | Recurrent sore throats | |
| Hoarseness | | Neck Stiffness | |
| Coughing up blood | | Chronic Cough | |
| Chest Pressure/Tightness on exertion | | Chest Pressure/Tightness at rest | |
| Feeling dizzy or off-balance | | Pain in legs while walking | |
| Change in appetite | | Abdominal burning pain | |
| Nausea | | Diarrhea | |
| Change in bowel habits | | Rectal Bleeding | |
| Painful urination | | Change in urinary habits | |
| Breast Pain | | Weight Gain # of pounds gained | |
| Night Sweats | | Generalized Body Aches | |
| Change in vision | | Change in hearing | |
| Frequent nosebleeds | | Recurrent gum or tooth infections | |
| Constant sinus drainage | | Trouble swallowing | |
| Swollen glands | | Shortness of breath on exertion | |
| Shortness of breath laying down | | Coughing up phlegm in morning | |
| Feeling faint or almost passing out | | Swollen ankles or feet | |
| Heartburn or indigestion | | Abdominal cramping pain | |
| Vomiting | | Constipation | |
| Blood in urine or stool | | Frequent or urgent urination | |
| Head injury and loss of consciousness | | Vaginal discharge or odor | |
| Change in menstrual periods | | Change in sexual desire | |
| Breast lump | | Nipple discharge | |
| Testicular pain | | Skin rash | |
| Easy bruising or bleeding | | Changes in hair | |
| Trouble sleeping | | Depression | |
| Muscle weakness or pain | | Tingling in hands or feet | |
| Joint swelling or joint pain | | Testicular swelling | |
| Changes in skin or moles | | Lumps in neck, underarms, or groin | |
| Sensation of being too hot or cold | | Nervousness, panic | |
| Mood swings | | Numbness | |
| Memory loss | | Seizures or convulsions | |
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