Patient Medical History and Review of Systems

Patient Name

First NameMiddle NameLast Name

Patient Date of Birth

MonthDayYear

Today's Date

MonthDayYear

Referring Doctor

Height

Weight

Occupation

Retired from

Race

Ethnicity

Reason for today’s visit

Previous medical issues or injuries:

Family history of any medical issues:

Have you ever smoked?

Packs per day: How many years? years

Any alcohol?

How much?

Any other drugs?

If yes, specify:

Vaping?

# per day

Any Caffeine?

How much?

Do you have any allergies to medication?

If so, what medications:

Are you allergic to contrast?

If so, what type:

What surgeries have you had?

Medication list (dosage):

Do you take any blood thinners?

Please list medications you currently take including aspirin:

Social history:

What Pharmacy do you use?

Street/City

Have you ever experienced problems with following? Please check the appropriate box.

Constitutional

Rows
Weight Gain
Weight Loss
Night Sweats
Insomnia

Neurological:

Rows
Numbness
Weakness
Headaches
Stroke

Musculoskeletal:

Rows
Arthritis

Eyes:

Rows
Double vision
Vision loss
Glasses

Ear, Nose, Throat:

Rows
Hearing Loss
Ringing noise
Nasal congestion
Sinus problems
Trouble swallowing
Hoarseness

Respiratory:

Rows
Trouble breathing
Snoring
Asthma
Tuberculosis (TB)
Pneumonia or Bronchitis

Allergic/Immunologic:

Rows
Sneezing
Itchy eyes/nose throat
Allergy shots
Skin Rash
HIV

Cardiovascular:

Rows
High cholesterol
Heart Disease
Rheumatic fever
Heart murmur
High Blood Pressure

Gastrointestinal:

Rows
Indigestion / Heartburn
Ulcers
Hepatitis
Bloody or black stool

Endocrine:

Rows
Diabetes
Thyroid disease
Pituitary disease

Genitourinary:

Rows
Bladder control
Prostate disease
Kidney disease

Hematologic:

Rows
Bleeding disorder
Anemia

Psychiatric:

Rows
Depression
Other

Today's Date

MonthDayYear

Patient Name (Print):

Signature