INITIAL VISIT HEALTH HISTORY FORM

Amory de Roulet, MD MPH | VI Medical & Surgical Associates, LLC

All information contained in this questionnaire is strictly confidential and will become part of your medical record.

Last Name

First Name

Middle Initial

M F

DOB:

Age

Home Address:

City:

State:

Zip:

Home Phone:

Mobile Phone:

Fax:

Email:

Referring MD:

Specialty:

Phone:

Fax:

Address:

City:

State:

Zip:

Primary/Other MD:

Specialty:

Phone:

Fax:

Address:

City:

State:

Zip:

Nearest Relative/Emergency Contact:

Relation to you:

Work Phone:

Home Phone:

Fax:

MEDICAL HISTORY

Have you ever had any of the following conditions?

Angina

Yes No

Date:

Stomach Ulcer

Yes No

Date:

Heart Attack

Yes No

Date:

Liver Disease/Cirrhosis

Yes No

Date:

Heart Failure

Yes No

Date:

Kidney Disease/Dialysis

Yes No

Date:

Heart Murmur

Yes No

Date:

Kidney Stones

Yes No

Date:

High Blood pressure

Yes No

Date:

Blood Clots/DVT

Yes No

Date:

Diabetes

Yes No

Date:

Excessive Bleeding

Yes No

Date:

Stroke

Yes No

Date:

Bone Loss/Osteoporosis

Yes No

Date:

Asthma

Yes No

Date:

Bone Fracture

Yes No

Date:

Specify:

Emphysema

Yes No

Date:

Cancer

Yes No

Date:

Specify:

List any other medical problems that your Doctors have diagnosed

Previous Surgery

Add Previous Surgery

List your prescribed drugs and over-the-counter drugs, including vitamins, supplements, and inhalers.

Add Drug

Add Allergies to Medications/Foods

Social History/Lifestyle

Occupation

If retired, Former occupation

Who lives at Home with You?

What kind of regular Exercise do you get?

(Women) Are you Pregnant?

Yes No

(Women) Are you presently trying to conceive a child?

Yes No

Smoking

Yrs Smoked

Quit Date

Alcohol

FAMILY HEALTH HISTORY

Do any of the following conditions run in your family?

Thyroid Disease

High Calcium

High Blood Pressure

Stomach Ulcers

Cancer

Difficulty with Anesthesia

Excessive Bleeding

Other

If Thyroid Disease, specify:

If Cancer, specify:

If other, List:

PLEASE DETAIL THESE AND ANY OTHER SIGNIFICANT FAMILY HEALTH PROBLEMS BELOW

Father: Age

Significant Health Problems

Mother: Age

Significant Health Problems

Add Siblings

Add Children

Add Other

REVIEW OF SYSTEM

Please explain any yes answer in the space provided

Constitutional

Explain

Eyes:

Explain

Ear/Nose/Throat/Mouth:

Explain

Respiratory:

Explain

Cardiovascular

Explain

Musculoskeletal:

Explain

Gastrointestinal:

Explain

Genitourinary:

Explain

Neurological/Psychological:

Explain

Integumentary

Explain

Hematologic/Lymphatic:

Location/Explain

Explain

Allergic/Immunologic:

Explain

Other:

List/Explain

AUTHORIZATION:

I authorize transfer of my Medical Records to VI Medical & Surgical Associates and my referring physicians (Listed on front of page).

Print Name:

Signed:

Date:

Your information will be encrypted.