hermosaplasticsurgery.com - Health History Form

Health History
Patient Name
Today's Date

MonthDayYear
Date
Age
Birthdate

MonthDayYear
Date
Date of last physical examination

MonthDayYear
Date
What is your reason for visit?
- Symptoms -

Check (V) conditions you currently have or have had in the past year.
ChillsDepressionDizzinessFaintingFeverForgetfulnessHeadacheLoss of sleepLoss of weightNervousnessNumbnessSweats
ArmsHipsBackLegsFeetNeckHandsShoulders
Blood in urineFrequent urinationLack of bladder controlPainful urination
Appetite poorBloatingBowel changesConstipationDiarrheaExcessive hungerExcessive thirstGasHemorrhoidsIndigestionNauseaRectal bleedingStomach painVomitingVomiting blood
Chest painHigh blood pressureIrregular heart beatLow blood pressurePoor circulationRapid heart beatSwelling of anklesVaricose veins
Bleeding gumsBlurred visionCrossed eyesDifficulty swallowingDouble visionEaracheEar dischargeHay feverHoarsenessLoss of hearingNosebleedsPersistent coughRinging in earsSinus problemsVision - FlashesVision - Halos
Bruise easilyHivesItchingChange in molesRashScarsSore that won't heal
Breast lumpErection difficultiesLump in testiclesPenis dischargeSore on penisOther
Abnormal Pap SmearBleeding between periodsBreast lumpExtreme menstrual painHot flashesNipple dischargePainful intercourseVaginal dischargeOther
Date of last menstrual period

MonthDayYear
Date
Date of last Pap Smear

MonthDayYear
Date
YesNo
YesNo
Number of children
- Conditions -
AIDSAlcoholismAnemiaAnorexiaAppendicitisArthritisAsthmaBleeding DisordersBreast LumpBronchitisBulimiaCancerCataractsChemical DependencyChicken PoxDiabetesEmphysemaEpilepsyGlaucomaGoiterGonorrheaGoutHeart DiseaseHepatitisHerniaHerpesHigh CholesterolHIV PositiveKidney DiseaseLiver DiseaseMeaslesMigraine HeadachesMiscarriageMononucleosisMultiple SclerosisMumpsPacemakerPneumoniaPolioProstate ProblemPsychiatric CareRheumatic FeverScarlet FeverStrokeSuicide AttemptThyroid ProblemsTonsillitisTuberculosisTyphoid FeverUlcersVaginal InfectionsVenereal Disease
- Medications -
List medications you are currently taking
Pharmacy Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
- Allergies -
- Family History -

Relation

Rows	Age	State of Health	Age of Death	Cause of Death
Father
Mother
Brother 1
Brother 2
Brother 3
Brother 4
Sister 1
Sister 2
Sister 3
Sister 4

Check if, your blood relatives had any of the following diseases listed below:

Rows	Check	Relationship to you
Arthritis, Gout
Asthma, Hay Fever
Cancer
Chemical Dependency
Diabetes
Heart Disease, Strokes
High Blood Pressure
Kidney Disease
Tuberculosis

- Hospitalizations -
YesNo
If yes, please give approximate dates
- Pregnancies -
- Health Habits -
CaffeineTobaccoStreet DrugsOther
- Occupational -
StressHazardous SubstancesHeavy LiftingOther
Occupation
To the best of my knowledge, the above information is complete and correct. I understand that it is my résponsibility to inform my doctor if I, or my minor child, ever have a change in health.
Signature of Patient, Parent, Guardian or Personal Representative
Date

MonthDayYear
Date
Name of Patient, Parent, Guardian or Personal Representative
Relationship to Patient
Should be Empty:

Health History

- Symptoms -

- Conditions -

- Medications -

- Family History -

- Health Habits -

- Occupational -