MEDICAL HISTORY
Name __________________________________________________ Date of Birth ____________
|
|
Now |
Past |
|
Now |
Past |
|
Now |
Past |
General |
|
|
Urinary |
|
|
Endocrine |
|
|
|
Weight loss |
|
|
Frequent urination |
|
|
Thyroid Problem |
|
|
|
Fever/Chills |
|
|
Burning |
|
|
Diabetes |
|
|
|
Fatigue |
|
|
Blood in urine |
|
|
|
|
|
|
Headaches |
|
|
Urinary infection |
|
|
Blood |
|
|
|
|
|
|
Kidney Stones |
|
|
Blood clots |
|
|
ENT |
|
|
Incontinence |
|
|
Bleeding problems |
|
|
|
Hearing loss |
|
|
Sexual difficulty |
|
|
Leukemia |
|
|
|
Ringing ears |
|
|
Male testicle pain |
|
|
Anemia |
|
|
|
Blurred vision |
|
|
Female painful menses |
|
|
Phlebitis |
|
|
|
Earaches |
|
|
Female vag. discharge |
|
|
Enlarged spleen |
|
|
|
Nose bleeds |
|
|
|
|
|
Hepatitis |
|
|
|
Bleeding gums |
|
|
Musculoskeletal |
|
|
HIV |
|
|
|
Sore throat |
|
|
Joint pain |
|
|
AIDS |
|
|
|
Swollen glands |
|
|
Stiffness |
|
|
|
|
|
|
|
|
|
Weakness |
|
|
|
|
|
Heart |
|
|
Back pain |
|
|
|
|
|
|
Heart failure |
|
|
Cold feet or hands |
|
|
|
|
|
|
Heart Attack |
|
|
Poor circulation |
|
|
|
|
|
|
Angina |
|
|
|
|
|
|
|
|
|
Leg swelling |
|
|
Skin/Breast |
|
|
|
|
|
|
Palpitations |
|
|
Rash/itching |
|
|
|
|
|
|
Rheumatic fever |
|
|
Change in color |
|
|
|
|
|
|
High Blood
Pressure |
|
|
Varicose veins |
|
|
|
|
|
|
|
|
|
Breast pain |
|
|
|
|
|
Lungs |
|
|
Breast lump |
|
|
|
|
|
|
Pneumonia |
|
|
Breast discharge |
|
|
|
|
|
|
Emphysema |
|
|
Breast cancer |
|
|
|
|
|
|
Bronchitis |
|
|
|
|
|
|
|
|
|
Cancer |
|
|
Neuro |
|
|
|
|
|
|
Shortness of breath |
|
|
Dizzy spells |
|
|
|
|
|
|
Spitting blood |
|
|
Numbness |
|
|
|
|
|
|
Wheezing/Asthma |
|
|
Seizures |
|
|
|
|
|
|
|
|
|
Tremors |
|
|
|
|
|
Gastrointestinal |
|
|
Paralysis |
|
|
|
|
|
|
Poor appetite |
|
|
Head Injury |
|
|
|
|
|
|
Diarrhea |
|
|
|
|
|
|
|
|
|
Constipation |
|
|
Psychiatric |
|
|
|
|
|
|
Nausea/Vomiting |
|
|
Memory loss |
|
|
|
|
|
|
Painful bowel move. |
|
|
Nervousness |
|
|
|
|
|
|
Rectal bleeding |
|
|
Depression |
|
|
|
|
|
|
Abdominal Pain |
|
|
Insomnia |
|
|
|
|
|
|
Gall stones |
|
|
|
|
|
|
|
|
Previous Surgeries and Dates: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Social History:
Smoking No Yes How Much __________________ How many years_________________
Alcohol No Yes How Much __________________
Marital Status: S M D W
Family History:
Age Medical problems or cause of death
Father ____ ________________________________________________________________________
________________________________________________________________________
Mother ____ ________________________________________________________________________
________________________________________________________________________
Siblings ____ ________________________________________________________________________
____ ________________________________________________________________________
____ ________________________________________________________________________
____ ________________________________________________________________________
____ ________________________________________________________________________
Current Medications and Doses
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Drug Allergies and Reaction
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________