Past & Present Medical History

If Cancer, please specify type

If Other, please specify

If Prostate Surgery, please specify

If Other, please specify

REVIEW OF SYSTEMS

Please check all that apply.

I. GENERAL

Appetite loss

Fatigue

Fever

Weight loss

II. SKIN

Change in wart/mole

Dryness

Itching

Rash

IV. NECK

Neck mass

Neck pain

Neck stiffness

V. RESPIRATORY

Chronic cough

Difficulty breathing

Wheezing

VI. CARDIOVASCULAR

Chest pain

Elevated blood pressure

Palpitations

Shortness of breath

VII. GI

Abdominal pain

Bloody stool

Change in bowel habits

Difficulty swallowing

Indigestion

Vomiting

VIII. GU

Change in bladder habits

Discharge

Painful urination

Urgency

IX. MUSCULOSKELETAL

Decreased range of motion

Joint pain

Muscle pain

Muscle weakness

X. NEUROLOGICAL

Attention deficit

Dizziness

Headaches

Incoordination

Tremors

XI. PSYCHIATRIC

Anxiety

Depression

Inability to concentrate

Memory loss

XII. ENDOCRINE

Cold intolerance

Excessive thirst

Excessive urination

XIII. HEMATOLOGY

Easy bruising

Enlarged lymph nodes

Excessive bleeding

FAMILY HISTORY

If any BLOOD RELATIVE has had any of the following please indicate the relationship to you next to the condition. (Be sure to mention if the relative is on your mother’s or father’s side of the family.)

Conditions

Alcoholism

Relationship

Allergies

Relationship

Arthritis

Relationship

Asthma

Relationship

Bipolar Disorder

Relationship

Cancer

Relationship

Cerebrovascular Accident

Relationship

Chronic Bronchitis

Relationship

Coagulation Disorder

Relationship

Congestive Heart Failure

Relationship

Chronic Lung Disease

Relationship

Diabetes

Relationship

Emphysema

Relationship

Heart Disease

Relationship

Hypercholesterolemia

Relationship

Hypertension

Relationship

Hypoglycemia

Relationship

Kidney Disease

Relationship

Malignant Hyperthermia

Relationship

Osteoporosis

Relationship

Parkinson’s Disease

Relationship

Seizure Disorder

Relationship

DEMOGRAPHICS

(Please circle all that apply)

Race

American Indian or Alaska Native

Asian

Black or African American

More than one race

Native Hawaiian

Other Pacific Islander

White

Language

Bithdate

SOCIAL HISTORY

(Please check all that apply)

Tobacco Use

None

Cigarettes

Chew

Cigars

Pipe

Dip

How Much

Previous Tobacco Use

None

Cigarettes

Cigars

Pipe

Dip

Other

How Much

How Long

Date Quit

Alcohol Use

None

Minimal

Moderate

Heavy

Previous user

Seldom/Rare

Caffeine Use

None

Minimal

Moderate

Large

Pets in home

None

Dog(s)

Cat(s)

Other(s)

If other, please specify

RX HISTORY

(Please fill out)

Current Medications (include name, strength, and dosage information)

Drug Allergies

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Patient Signature

Date

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