| HISTORY AND PHYSICAL | ||||||||||||
| Name | Age | Date of Birth | Date | |||||||||
| To properly care for you, we need a complete and thorough summary of your medical history. | Male____ | Female____ | ||||||||||
| What is your chief complaint? | SYSTEMS REVIEW (circle) | |||||||||||
| CONSTITUTION/ GENERAL | ||||||||||||
| General Health: | Good Fair Poor | |||||||||||
| Circle dominant side: Right or Left | Recent weight gain or loss | No | Yes | |||||||||
| Family Doctor/Internalist: | Complaints of fever | No | Yes | |||||||||
| Drug and other allergies: | Reactions to anesthesia | No | Yes | |||||||||
| HEMATOLOGIC | ||||||||||||
| Current Medications: | Bruise Easily | No | Yes | |||||||||
| ____________________________________________________ | Tendency to bleed excessively | No | Yes | |||||||||
| ____________________________________________________ | History of Blood Clotting | No | Yes | |||||||||
| ____________________________________________________ | CENTRAL NERVOUS AND PSYCHIATRIC | |||||||||||
| ____________________________________________________ | Difficulty sleeping | No | Yes | |||||||||
| ____________________________________________________ | Troubled by depression | No | Yes | |||||||||
| ____________________________________________________ | Troubled by anxiety | No | Yes | |||||||||
| ____________________________________________________ | Psychiatric illness | No | Yes | |||||||||
| ____________________________________________________ | Mental health illness | No | Yes | |||||||||
| ____________________________________________________ | Severe headaches | No | Yes | |||||||||
| ____________________________________________________ | Problems with dizziness | No | Yes | |||||||||
| ____________________________________________________ | Seizures or convulsions | No | Yes | |||||||||
| ____________________________________________________ | RESPIRATORY AND CARDIOVASCULAR | |||||||||||
| ____________________________________________________ | Cough | No | Yes | |||||||||
| ____________________________________________________ | Shortness of breath | No | Yes | |||||||||
| Chest pain | No | Yes | ||||||||||
| Palpitation/fluttering heart | No | Yes | ||||||||||
| SOCIAL HISTORY: | Elevated blood pressure | No | Yes | |||||||||
| Pacemaker or Defibrillator | No | Yes | ||||||||||
| Married? Yes No | GENITOURINARY/ GASTROINTESTINAL | |||||||||||
| Occupation: | Burning with urination | No | Yes | |||||||||
| Persons with whom you live: | Frequent urination | No | Yes | |||||||||
| Number of children: | Number of Live Births: | Mentural cylcle problems | No | Yes | ||||||||
| Are you pregnant? Yes No | Date of last menstrual period_______ | Prostate problems | No | Yes | ||||||||
| Tobacco use? Yes No | Packs per day | Stomach pain or burning | No | Yes | ||||||||
| Years of tobacco use | Frequent loose stools | No | Yes | |||||||||
| Alcohol use (circle) | None Rarely Moderate Daily | Frequent constipation | No | Yes | ||||||||
| FAMILY HISTORY: | MUSCULOSKELETAL | No | Yes | |||||||||
| Any history of osteoarthritis, rheumatoid arthritis, gout, back surgeries, disc | Joint pain | No | Yes | |||||||||
| disease, anesthetic problems, diabetes, bleeding disorders, mental illness, | Rheumatoid arthritis | No | Yes | |||||||||
| heart or stroke problems, etc. | Gout | No | Yes | |||||||||
| Mother: | Back problems | No | Yes | |||||||||
| Father: | SKIN/ BREAST | No | Yes | |||||||||
| Maternal Grandparents: | Frequent rashes | No | Yes | |||||||||
| Paternal Grandparents: | Breast pain or tenderness | No | Yes | |||||||||
| Siblings: | Nipple discharge | No | Yes | |||||||||
| HEALTH MAINTENANCE: | Breast lumps or masses | No | Yes | |||||||||
| List last physical exam and date | Date | ENDOCRINE | ||||||||||
| EKG | Excessive thirst | No | Yes | |||||||||
| CXR | Excessive urination | No | Yes | |||||||||
| MAMMO | HEENT | |||||||||||
| PATIENT SIGNATURE | Difficulty swallowing | No | Yes | |||||||||
| Ringing or Drainage in ears | No | Yes | ||||||||||
| Frequent earaches | No | Yes | ||||||||||
| ** Current & Past Problems &Surgeries On Next Page** | Wear glasses/ contacts | No | Yes | |||||||||
| Uncorrectable hearing | No | Yes | ||||||||||
| Double or blurry vision | No | Yes | ||||||||||
| CURRENT & PAST PROBLEMS AND SURGERIES | ||||||||||||
| including serious and chronic illnesses | ||||||||||||
| Date | Current Medical Problems | Doctor | ||||||||||
| Date | Past Medical Problems & Surgeries | Doctor/Surgeon | ||||||||||
| PATIENT SIGNATURE | ||||||||||||