Patient Health History

Full Name

Allergies

No Known Medication Allergies

Latex

Band-Aid/Adhesive

Medication Allergies

Please list below

Medication Allergies

Social History

Have you used any tobacco/nicotine products in the last 12 months?

Yes

No

Are you a former smoker?

Yes

No

When did you quit?

Do you drink alcohol?

Yes

No

On average, how many alcoholic beverages do you consume per week?

Do you use drugs (cocaine, methamphetamines)?

Yes

No

Which drugs do you use?

Are you pregnant or nursing?

Yes

No

Medical History

Which type of cancer(s)?

Please List Any Other Current Health Problems

Alternatively, you can upload your health history here

Add file

Please upload a file

Medication History

Please List All Current Medications (Including OTC Medications)

Alternatively, you can upload your medication list here

Add file

Please upload a file

Surgical History

Pacemaker?

Yes

No

When was the procedure?

Heart Stent(s) or Valve(s)?

Yes

No

When was the procedure?

Joint Replacement?

Yes

No

What joint(s)? When was/were the procedure(s)?

Organ Transplant?

Yes

No

What organ? When was the procedure?

Please List Other Previous Surgeries

Dermatology History

**Only required if your visit is with our dermatologist**

Personal history of skin cancer?

Yes

No

What type(s)?

Family history of skin cancer?

Yes

No

What type(s)?

Tanning Bed Use?

Yes

No

Sunscreen Use?

Yes

No

Review of Systems

Please check any symptoms below that you feel are affecting your health

General

Fever

Chills

Fatigue

Unexplained weight loss

Night sweats

Sleep problems

Skin

New or changing skin growth

Unexplained rash

Head

Headache

Recent trauma

Eyes

Blurry vision

Loss of vision

Eye pain

Eye discharge

Ears

Loss of hearing

Ringing in ears

Ear pain

Ear discharge

Nose

Frequent bloody nose

Sinus pain

Post-nasal drainage

Congestion

Mouth

Tooth pain

Sores

Bleeding gums

Throat

Hoarseness

Soreness

Difficulty swallowing

Painful swallowing

Neck

Pain

Stiffness

Swelling

Chest

Chest wall pain

Nipple discharge

Breast changes or lumps

Lungs

Cough

Shortness of breath

Wheezing

Heart

Murmurs

Palpitations

Pain with exertion

Stomach

Nausea

Vomiting

Diarrhea

Constipation

Abdominal pain

Urinary Tract

Frequent urination

Pain with urination

Blood in urine

Musculoskeletal

Joint pain

Joint swelling

Joint stiffness

Muscle pain

Nervous System

Dizziness

Light-headedness

Vertigo

Seizures

Weakness or numbness in any body part

Mental Health

Feelings of nervousness/anxiety

Depressed mood

Panic attacks

Crying episodes

Blood/Lymph

Easy bruising

Bleeding tendency

Swollen lymph nodes

Family History

Please check which family members have had the following health problems:

Dad

Mom

Grandpa

Grandma

Brother

Sister

Alcoholism

Dad

Mom

Grandpa

Grandma

Brother

Sister

Anemia

Dad

Mom

Grandpa

Grandma

Brother

Sister

Anxiety

Dad

Mom

Grandpa

Grandma

Brother

Sister

Arthritis

Dad

Mom

Grandpa

Grandma

Brother

Sister

Asthma

Dad

Mom

Grandpa

Grandma

Brother

Sister

Bleeding Problem

Dad

Mom

Grandpa

Grandma

Brother

Sister

Cancer

Dad

Mom

Grandpa

Grandma

Brother

Sister

Cirrhosis

Dad

Mom

Grandpa

Grandma

Brother

Sister

Dementia

Dad

Mom

Grandpa

Grandma

Brother

Sister

Depression

Dad

Mom

Grandpa

Grandma

Brother

Sister

Eczema

Dad

Mom

Grandpa

Grandma

Brother

Sister

Eye Problems/Glaucoma

Dad

Mom

Grandpa

Grandma

Brother

Sister

Heart Disease

Dad

Mom

Grandpa

Grandma

Brother

Sister

High Blood Pressure

Dad

Mom

Grandpa

Grandma

Brother

Sister

High Cholesterol

Dad

Mom

Grandpa

Grandma

Brother

Sister

Kidney Disease

Dad

Mom

Grandpa

Grandma

Brother

Sister

Liver Disease

Dad

Mom

Grandpa

Grandma

Brother

Sister

Lung Disease

Dad

Mom

Grandpa

Grandma

Brother

Sister

Osteoporosis

Dad

Mom

Grandpa

Grandma

Brother

Sister

Parkinson's Disease

Dad

Mom

Grandpa

Grandma

Brother

Sister

Peptic Ulcer Disease

Dad

Mom

Grandpa

Grandma

Brother

Sister

Seizures

Dad

Mom

Grandpa

Grandma

Brother

Sister

Stroke

Dad

Mom

Grandpa

Grandma

Brother

Sister

Thyroid Disease

Dad

Mom

Grandpa

Grandma

Brother

Sister

Please list any other pertinent family history

Patient Health History

Alliance Health

Alliance Health