Patient History

Name:*
DOB:*
Date:*

MonthDayYear
Date
Chief Complaint: What is the reason for your visit today( please describe problem in detail)*
ArthritisEpilepsy/seizuresPsychiatric diseaseCancerHeart problemsStrokeDepressionHeart surgeryThyroidDiabetesHigh blood pressureNoneOther
Previous Surgeries: Please list past surgeries with approximate date:*
InfluenzaPneumococcalTetanusShinglesHepatitis AHepatitis B
Please list all medications and what dose you are currently taking:*
Preferred Pharmacy*
City:*
Allergies: please list any allergies you have:*
YesNo
If yes, how many cigarettes/day?
YesNo
If yes, how much/week?
YesNo
If yes, how many cups or cans/week?
YesNo
If yes, what type and frequency?
YesNo
yes, please describe:
Number of sexual partners in the last 12 months:*
MalesFemalesBoth
Is your father alive or deceased?
What kind of issues does your father have?
Is your mother alive or deceased?
What kind of health issues does your mother have?
Is your brother alive or deceased?
What kind of health issues does your brother have?
Is your sister alive or deceased?
What kind of health issues does your sister have?
Date of last menstrual period:

MonthDayYear
Date
Date of menopause:

MonthDayYear
Date
Number of pregnancies:
Miscarriages:
Abortions:
Patient Name:*
Date:*

MonthDayYear
Date
ChillsDecline in healthBleeding gumsChange in dentitionArthritisAsthmaChest painFatigueHoarsenessGoutJoint painCoughWheezingPalpitationsFeverWeaknessPostnasal dripBack problemsVaricose veinsWeight gainTongue burningVoice changesDeformitiesBronchitisExtremity(s) coolWeight lossJoint stiffnessCoughing bloodExtremity(s)lbsMuscle crampsMuscle stiffnessPleurisyPositive TB testHair loss on legs
ParalysisRestricted motionRecent chest X rayHeart murmurConstipationHeart test(s)Discharge from earsHearing aidDiarrheaHeartburnWeaknessSputumHigh blood pressureHearing impairmentHearing impairmentJaundiceTuberculosisHistory of heartLiver DiseaseRinging in earsAntacid useRectal bleedingDepressionBehavioral changeEczemaDizziness
DisorientationDisturbing thoughtsItchingDrynessRheumatic feverRecent EKGChange in frequencyHallucinationsExcessive stressEasy bruisabilityHair texture changeShort of breath onFrequent coldsHay fever
HivesShort of breath lyingNasal obstruction
Mood changesShort of breathNosebleedsExcessive thirstExcessive hungerNervousnessPsychiatric disordersMole increased sizeNail appearanceSwelling of legsSinus infectionsHemorrhoidsGallbladder diseaseUlcers on legsNail texture changeHepatitisAwakening toRashesFrequent sore throatsLaxative useBed wettingSkin color changeLoss ofTendernessNauseaRectal painBurningBlood inurineBlackoutsTonsils enlargedSwallowing problemVomitingIncontinenceVomiting bloodDifficulty starting streamWeight gainWeight lossCold intoleranceExcessive urinationDecreased appetiteMemory lossCoughingFrequencyFlank painNumbnessGoiterItchy eyesHeat intoleranceSpeech disordersAnemiaRecurrent infectionsItchy noseUrine discolorationPain on urinationIncreased thirstUrine odorNeck painStrokesTinglingBleeding easilyBlood clotsRunny noseRetention stonesThyroid troubleTremorsLumpsSneezingUnsteady gaitRadiation exposure
UrgencySwollen glands
Transfusion reactionBlurry vision
DizzinessDouble visionFaintingExcessive tearingHead injuryEye PainHeadachesInfectionsPainSensitivity to lightSweatsRecent injury
Vision Loss
Should be Empty: