Established Patient Medical Information

Patient Name

Date of Birth

Height

Weight

Shoe Size

How Long?

How many packs a day?

Quit

How long?

How Often

Quit

What type?

Other

If yes, what date?

Any other medical problems not listed above?

Have you had any SURGERIES or been HOSPITALIZED since you were seen last?

Yes No

If yes, please describe

MEDICATIONS: Are there are changes in your medications since you were seen last?

Yes No None at this time

ALLERGIES: Are there are changes in your medications since you were seen last?

Yes No No known drug allergies

Patient Name

Date of Birth

REVIEW OF SYMPTOMS: Are you CURRENTLY experiencing any of the following:

GENERAL

Chills

Fever

Unexplained Weight Gain

Unexplained Weight Loss

EYES

Eye Symptoms

EARS / NOSE / THROAT / MOUTH

Ears Symptoms

Nasal Symptoms

Throat / Mouth Symptoms

RESPIRATORY

Shortness of breath

Cough

Congestion

Changes in appetite

Constipation

Diarrhea

Indigestion

Nausea

Ulcers

Vomiting

MUSCULO

History of falls

Leg cramps

Muscle aches

Tenderness

SKIN

Skin Symptoms

Hair Symptoms

Nail Symptoms

NEUROLOGIC

Difficulty with balance

Headache

Lightheaded

Restless leg syndrome

Stroke

PSYCHIATRIC

Anxiety

Insomnia

Memory loss

Mood Changes

ENDOCRINE

Dry Skin

Hair Loss

Excessive sweating

Excessive thirst

Thyroid problems

HEMA / LYMPH

Excessive bleeding

Bruising

FAMILY HISTORY: Has any member of your immediate family been treated for the following?

Add Family History

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