brucejsachsmd.com - New Patient Medical Questionnaire

Answers all questions. If you do not know the answer or do not understand the question, insert a question mark.
Have you ever had any of the following? If so, indicate when. LEAVE NO BLANKS!!!

CONDITION

	NO	YES, WHEN?
Pneumonia
Severe Bronchitis
Pleurisy
Tuberculosis (Skin Test)
Tuberculosis (Infection)
Asthma (wheezing)
Chronic Bronchitis
Emphysema
Other Lung Trouble
Exposure to dust/fumes
Trouble Breathing
Excessive Snoring
Chest Pain
Abnormal Chest X-Ray
Coughed up Blood
Regularly Have Cough
Get Chest Colds Often

CONDITION

	NO	YES, WHEN?
Poor Appetite
Trouble Swallowing
Heartburn
Regurgitation of food
Regurgitation of Bile
Nausea/Vomiting
Abdominal Pain
Constipation
Diarrhea
Change in Bowels?
Hiatal Hernia
Esophageal Hernia
Duodenal Ulcer
Gastric Ulcer
Blood in Stool
Positive Stool Cards
Yellow Jaundice
Liver Trouble
Hepatitis
Gallbladder Trouble
Diarrhea/colitis
Diverticulitis
Parasitic Infection
Hernia
Digestive Disease

CONDITION

	NO	YES, WHEN?
Chest Pain
Heart Trouble
Heart Attack
Angina Pectoris
High Cholesterol
High Blood Pressure
Blackouts
Racing of Heart
Rheumatic Fever
Heart Failure
Abnormal EKG
Ankle Swelling
Take Water Pills-Past?
Take Water Pills-Now
LAST CHEST X-RAY
LAST EKG
LAST MAMMOGRAM
LAST PAP SMEAR
LAST COLONOSCOPY

CONDITION

	NO	YES, WHEN?
Hormone Problems
Thyroid Disease
Diabetes
Osteoporosis

CONDITION

	NO	YES, WHEN?
Muscle Pain
Back Pain
Joint Pain
Joint Swelling
Gout
Diagnosed with Arthritis?
Diagnosed with Rheumatism?

CONDITION

	NO	YES, WHEN?
Skin Rashes
Skin Cancer

CONDITION

	NO	YES, WHEN?
Kidney Disease
Nephritis
Protein in Urine
Albumin in Urine
Kidney Stones
Urinary Infection
Prostate Trouble
Syphilis
Gonorrhea
How Many Times Do You Urinate At Night?
How Many Times Do You Urinate Day?

CONDITION

	NO	YES, WHEN?
Breast Tumors
Breast Cysts?
Other Breast Disease?
# of Times Pregnant?
Miscarriages?
Last Pap Smear?
Had an Abnormal Pap?
Still Menstruating?
Your Last Period?
The One Before?
# of Live Births?
Do You Ever Bleed(spot) between Periods?
Do You Bleed After Intercourse?
What age did you begin to menstruate?
Have you had toxemia?
Have you had a hysterectomy?
Taking birth control pills?
How many days do your periods last?
Are your periods regular?
Are your periods heavy?
Length of cycle?
Last Period?
Have you bled since?

CONDITION (Have you ever had:)

	NO	YES, WHEN?
Anemia?
Bleeding?
Bruising Tendency?
Cancer?
Tumor?
X-Ray or Radiation Treatment?
Do you practice breast or testicular self exam

CONDITION (Have you ever had:)

	NO	YES, WHEN?
Neurological disease
Frequent headaches
Recurrent headaches
Loss of consciousness
Convulsions
Seizures
Head Injury
Stroke
Paralysis
Muscular weakness
Tremor
Abnormal movements
Difficulty in coordination
Difficulty in walking
Difficulty in speaking
Double vision
Loss of vision
Difficulty with memory
Dizziness

CONDITION (Have you Recently:)

	NO	YES, WHEN?
Experiences severe anxiety, panic or phobias?
Found it hard to concentrate?
Felt unable to enjoy your usual activities?
Had a weight change or eating disorder?
Had insomnia or excessive daytime sleepiness?
Been involved with domestic violence?
Felt depressed?
Thought yourself undeserving or worthless?
Felt excessively fatigued?
Had a nervous breakdown?
Under psychiatric care?
Had a drug or alcohol problem?
Would you like a consultation with a mental health professional?

CONDITION (Have you Recently:)

	NO	YES, WHEN?
Had you ever had:
Glaucoma
Other major eye disease
Deafness
Abnormal noises in the ear
Tetanus-Diphtheria
Pneumococcal Pneumonia (Pneumovax)
Influenza (Flu)

SPECIAL SENSE (Date Last Immunized For:)

	Year
Tetanus-Diphtheria
Pneumococcal Pneumonia (Pneumovax)
Influenza (Flu)

CONDITION (Have you ever had:)

	NO	YES, WHEN?
Asthma?
Eczema or other skin problems?
Hay fever or stuffy nose/sinuses?
Reaction to penicillin?
A Reaction to aspirin?

A reaction to any other drug? (Specify)

Rubella (German Measles) status?

Any Additional Information You Would Like to Provide

	Age if alive	Age at death	Status of Health or Cause of Death
Mother
Father
Spouse
Siblings:
Children:

MEDICAL HISTORY FORM

GENERAL HEALTH AND HABITS:

Exercise:

Smoking:

Nutrition:

Alcohol/Beverages:

PAST MEDICAL AND SURGICAL HISTORY:

REVIEW OF SYSTEMS

RESPIRATORY

DIGESTIVE

CIRCULATORY

ENDOCRINOLOGY

JOINTS

CUTANEOUS

URINARY

OBSTETRIC & GYNECOLOGICAL

HEMATOLOGY & ONCOLOGY

NEUROLOGICAL

MOOD

SPECIAL SENSE

ALLERGY & IMMUNOLOGY

CURRENT ALLERGIES TO MEDICATIONS / FOOD ALLERGIES / ANY ALLERGIES

MEDICATION LIST

PERSONAL HISTORY

FAMILY HEALTH