Patient Name
*
First
Last
Today's Date
*
Age
*
Birthdate
*
Date of last physical examination
What is your reason for visit?
*
Symptoms - Check symptoms you currently have or have had in the past year
General
Depression
Dizziness
Chills
Fainting
Fever
Forgetfulness
Headache
Loss of sleep
Loss of weight
Nervousness
Numbness
Sweats
Gastrointestinal
Poor appetite
Bloating
Bowel changes
Constipation
Diarrhea
Excessive hunger
Excessive thirst
Gas
Hemorrhoids
Indigestion
Nausea
Rectal bleeding
Stomach pain
Vomiting
Vomiting blood
Eye, Ear, Nose, Throat
Bleeding gums
Blurred vision
Crossed eyes
Difficulty swallowing
Double vision
Earache
Ear discharge
Hay fever
Hoarseness
Loss of hearing
Nosebleeds
Persistent cough
Ringing in ears
Sinus problems
Vision - Flashes
Vision - Halos
Men Only
Breast lump
Erection difficulties
Lump in testicles
Penis discharge
Sore on penis
Other
Women Only
Abnormal pap smear
Bleeding between periods
Breast lump
Extreme menstrual pain
Hot flashes
Nipple discharge
Painful intercourse
Vaginal discharge
Other
Date of last menstrual period
Date of last pap smear
Have you had a mammogram?
Yes
No
Are you pregnant?
Yes
No
Number of children
Muscle/Joint/Bone - Pain, weakness, numbness in:
Arms
Back
Feet
Hands
Hips
Legs
Neck
Shoulders
Genito-urinary
Blood in urine
Frequent urination
Lack of bladder control
Painful urination
Cardiovascular
Chest pain
High blood pressure
Irregular heart beat
Low blood pressure
Poor circulation
Rapid heart beat
Swelling of ankles
Varicose veins
Skin
Bruise easily
Hives
Itching
Change in moles
Rash
Scars
Sore that won't heal
Conditions - Check conditions you have or have had in the past
AIDS
Alcoholism
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding disorders
Breast lump
Bronchitis
Bulimia
Cancer
Cataracts
Chemical dependency
Chicken pox
Diabetes
Emphysema
Epilepsy
Glaucoma
Goiter
Gonorrhea
Gout
Heart disease
Hepatitis
Hernia
Herpes
High cholesterol
HIV positive
Kidney disease
Liver disease
Measles
Migraine headaches
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Pacemaker
Pneumonia
Polio
Prostate problem
Psychiatric care
Rheumatic fever
Scarlet fever
Stroke
Suicide attempt
Thyroid problems
Tonsilitis
Tuberculosis
Typhoid fever
Ulcers
Vaginal infections
Venereal disease
Medications - List medications you are currently taking
Pharmacy name
*
Pharmacy Phone
*
Allergies - To medications or substances
Family History
Fill in health information about your immediate family
Father
Age
State of health
Age at death
Cause of death
Mother
Age
State of health
Age at death
Cause of death
Brother
Age
State of health
Age at death
Cause of death
Brother
Age
State of health
Age at death
Cause of death
Brother
Age
State of health
Age at death
Cause of death
Sister
Age
State of health
Age at death
Cause of death
Sister
Age
State of health
Age at death
Cause of death
Sister
Age
State of health
Age at death
Cause of death
If your blood relatives had any of the following, list the condition and their relationship to you: Arthritis, Gout, Asthma, Hay fever, Cancer, Chemical dependency, Diabetes, Heart disease, Strokes, High blood pressure, Kidney disease, Tuberculosis, Other
Hospitalizations - List the year, name of hospital, and reason for hospitalization & outcome
Have you ever had a blood transfusion?
Yes
No
If yes, please give approximate dates
Serious illnesses/injuries - Please list the dates and outcomes of any serious illnesses/injuries
Pregnancy history - List year of birth, sex of birth, and complications (if any)
Health Habits - Check which substances you use and describe how much you use them
Caffeine
Yes
No
Drinks per week
Tobacco
Yes
No
Amount per week
Alcohol
Yes
No
Drinks per week
Recreational drugs
Yes
No
If yes, please list
Amount per week
List any other substances and the amount you use them per week
Occupational concerns - Check if your work exposes you to the following
Stress
Hazardous substances
Heavy lifting
Other
Your occupation
By entering my name below, I attest that, to the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
Name of patient, parent, guardian, or personal representative
*
First
Last
Relationship to patient
Submit