Medical History Form

Name

Date

Birth Date

Age

Referred By

Primary Care Doctor

Preferred Language

Pharmacy (Name, Location, Phone)

Race

Ethnicity

ALLERGIES

NONE

Iodine

Morphine

Codeine

Fentanyl

Latex

Penicillin

Sulfa

Other

If other, please specify

If allergic, what reaction:

Do you have any prior difficulties with sedation or anesthesia (nausea/vomiting, high intolerance, difficulty intubating, other)?

Yes No

If yes, please explain

If other, please specify.

Have you had any of the following done to evaluate the cause of your symptoms?

Laboratory tests or blood work

Explain

Radiology imaging (x-rays, ultrasounds, CAT scans, MRIs, barium studies).

Explain

Endoscopies (upper GI scope r/EGD, ERCP, colonoscopy).

Explain

Emergency room visits

Explain

*We appreciate that you Fax 305-598-0668 or email Info@drllaneza.net any pertinent medical records in advance of your visit*

What medications have you tried to treat your symptoms with (non-prescription and prescription)?

PAST MEDICAL ILLNESSES

If other, explain.

Pulmonary

Sleep Apnea

Asthma

Emphysema (COPD)

Pneumonia

Pulmonary Embolism

Sarcoidosis

Lung Cancer

Pleurisy

Other

If other, explain.

HEMATOLOGIC

Anemia

Blood Transfusion

Blood Clot

Hemochromatosis

Hodgkin's Disease

Lymphoma

Leukemia

Myelodysplasia

Other

If other, explain.

ENDOCRINE

Diabetes

Hypothyroidism

Hyperthyroidism

Thyroid Nodule

Goiter

Thyroid Cancer

Pituitary Problem

Adrenal Problem

Other

If other, explain.

BREAST

Fibrocystic Breast Changes

Breast Cancer (L or R)

Radiation

Chemotherapy

Other

If other, explain.

MUSCULOSKELETAL

Arthritis

Rheumatoid Arthritis

Osteoporosis

Osteopenia

Fibromyalgia

Polymyalgia Rheumatica

Lupus

Gout

Other

If other, explain.

EYES, EARS, NOSE, AND THROAT

Glaucoma

Cataracts

Macular Degeneration

Retinal Detachment

Allergic Rhinitis

Sinusitis

Oral Thrush

Sjogren's

Other

If other, explain.

DERMATOLOGIC

Eczema

Psoriasis

Vitiligo

Alopecia

Raynaud's Syndrome

Basal Cell Skin Cancer

Squamous Cell Skin Cancer

Melanoma

Other

If other, explain.

ONCOLOGIC

Any other malignant tumors or cancers not previously mentioned?

If selected, please list

INFECTIOUS DISEASE

Do you have any communicable disease, such as hepatitis, HIV, or sexually transmitted disease?

If selected, please explain

Any other hospitalizations or medical conditions not previously mentioned?

If selected, please explain

If other, explain.

FAMILY HISTORY

Biliary Tract Cancer

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Brain Cancer

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Breast Cancer

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Celiac Disease

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Cirrhosis

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Colon Polyps

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Colorectal Cancer

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

*** Age of Diagnosis

Crohn's Disease

Which member has been diagnosed?

Mother

Father

Sister

Brother

Grandmother

Grandfather

Diabetes

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Heart Disease

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Ovarian cancer

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Pancreatic Cancer

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Stomach Cancer

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Ulcerative colitis

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

Uterine cancer

Which member has been diagnosed?

Father

Mother

Son

Daughter

Brother(s)

Sister(s)

Grandmother

Grandfather

SOCIAL HISTORY

Occupation

Chldren (ages and general health)

Do you drink alcohol?

Yes No

How many glasses do you drink per day?

Per week?

Did you ever drink alcohol in the past?

Yes No

How many glasses did you drink per day?

Per week?

Do you have any problems with alcohol or drug use?

Do you use tobacco currently?

Yes No

Number of packs per day?

For how many years?

Did you use tobacco in the past?

Yes No

Vaping Electronic Cigarettes

When did you quit?

Packs per day?

How many years?

MEDICATIONS

Please be certain to include birth control pills, hormones, and ALL non-prescription medications, such as anti-inflammatories (i.e. aspirin, Advil, Motrin, Aleve, ibuprofen), acid blockers (i.e. Zantac, Pepcid, Tagamet, Prilosec OTC), topical hemorrhoid creams (i.e. Anusol, Preparation H), vitamins, and herbal supplements.

Medications

Dosage

Frequency

Add medication

REVIEW OF SYSTEMS

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Patient’s Signature or Patient’s Legal Guardian’s Signature

Date

Physician’s Initials

Date

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