MEDICAL HISTORY

 

Name __________________________________________________                     Date of Birth ____________

 

Please check the box if you have the problem now or in the past  

	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

Please complete the reverse side

 

 

 

 

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

________________________________________________________________________

                                    ________________________________________________________________________

                                    ________________________________________________________________________