| NAME_______________________________________________________________ |
TODAY'S DATE _______________________ |
|
| AGE__________________________________ | BIRTHDATE ___________________ | DAYTIME PHONE ______________________ |
| HISTORY OF PAST ILLNESS | Have you had: | ||||
| CHILDHOOD: | |||||
|
Yes
No |
|
Yes No | ||
|
Yes
No |
|
Yes No | ||
|
Yes
No |
|
Yes No | ||
|
Yes
No |
|
Yes No | ||
|
Yes
No |
|
Yes No | ||
|
Yes
No |
_________________________________________ | |||
| ADULT: | |||||
|
Yes
No |
||||
|
Yes
No |
||||
|
|||||
| OPERATIONS: | |||||
| Have you had surgery? | Yes No | ||||
| List: 1.__________________________________________________ | 4._____________________________________________________ |
||||
| 2.__________________________________________________ | 5._____________________________________________________ | ||||
| 3.__________________________________________________ | 6._____________________________________________________ | ||||
| INJURIES: | |||||
| Have you had any broken bones? |
Yes
No |
||||
| Have you had any head injuries or concussions? |
Yes
No |
||||
| Have you ever been knocked unconscious? |
Yes
No |
||||
| FAMILY HISTORY | IF Living:
Age Health |
If Deceased:
Age (at death) & Cause |
Has any blood relative ever had: | |||
| Mother | Cancer |
Yes
No |
||||
| Father | Tuberculosis |
Yes
No |
||||
| Brother/Sister | Diabetes |
Yes
No |
||||
| Heart Trouble |
Yes
No |
|||||
| Husband/Wife | High Blood Pressure |
Yes
No |
||||
| Son/Daughter | Stroke |
Yes
No |
||||
| Convulsions |
Yes
No |
|||||
| Suicide |
Yes
No |
|||||
| Insanity |
Yes
No |
|||||
| Bleeding Tendency |
Yes
No |
|||||
| Gout or other Arthritis |
Yes
No |
|||||
| SOCIAL HISTORY | |||||
Check One |
Single Married Seperated Divorced Widowed | ||||
| Are you living with your spouse? Yes No | |||||
| Is your sex life satisfactory? Yes No | |||||
| Do you have dependents at home? Yes No | |||||
| Alcoholic Beverages: | Never Rarely Moderately Daily Ever......... Yes No | ||||
| Tobacco: | Cigarettes Packs a Day ____ Don't Use Ever......... Yes No | ||||
| Are you employed? | Full time Part time | ||||
| What is your job? | __________________________________________________________ | ||||
| Are you exposed to fumes, dust or solvents? | Yes No | ||||
| Education: | (Years) |
Time you have lost from work because of your health during the past? | |||
|
____________ | Six Months
|
|||
|
____________ | One Year
|
|||
|
____________ | Five Years
|
|||
|
____________ | ||||
| SYSTEMIC REVIEW | Do you have any of the following? |
||
General: |
Cardiovascular: |
||
| Recent weight changes? | Yes No | Chest pain or angina pectoris | Yes No |
| Have you been in good general health most of your life? | Yes No | Shortness of breath with walking or lying down | Yes No |
Skin: |
Diffuculty walking two blocks | Yes No | |
| Skin Disease | Yes No | Heart trouble or heart attacks | Yes No |
| Jaundice | Yes No | High blood pressure | Yes No |
| Hives, ecxema or rash | Yes No | Swelling of hands, feet or ankles | Yes No |
| Frequent infection or boils | Yes No | Awakening at night smothering | Yes No |
| Abnormal pigmentation | Yes No | Heart murmur | Yes No |
Head-Eye-Ear-Nose-Throat: |
Gastrointestinal: |
||
| Eye disease or injury | Yes No | Peptic ulcer (stomach or duodenal) | Yes No |
| Do you wear glasses? | Yes No | Vomiting blood or food | Yes No |
| Double vision | Yes No | Gallbladder disease | Yes No |
| Headaches | Yes No | Liver trouble | Yes No |
| Glaecoma | Yes No | Hepatitis | Yes No |
| Itching eyes or nose | Yes No | Bleeding bowel movements | Yes No |
| sneezing or runny nose | Yes No | Black stools | Yes No |
| Nosebleeds | Yes No | Hemorrhoids or piles | Yes No |
| Chronic sinus trouble | Yes No | Frequent diarrhea | Yes No |
| Ear disease | Yes No | Recent changes in bowel habits | Yes No |
| Impaired hearing | Yes No | Heartburn or indigestion | Yes No |
| Dizziness or translent episodes of unconscious | Yes No | Cramping or pain in the abdomen | Yes No |
| Neck: | Does food stick in throat | Yes No | |
| Stiffness | Yes No | Gynecological: |
|
| Thyroid trouble | Yes No | Age period started | _______________ |
| Enlarged glands | Yes No | How long do periods last? | __________Days |
Respiratory: |
Number of pregnacies | _______________ | |
| URI (cold) now | Yes No | Number of miscarriages | _______________ |
| Spitting up blood | Yes No | Date of last cancer smear & results | __/__/___ ________ |
| Chronic or frequent cough | Yes No | ____________________________________________________ | |
| Asthma or Wheezing | Yes No | Frequency of periods, every | ______ Days |
| Diffuculty breathing | Yes No | Any pain with your periods? | Yes No |
| Any trouble with lungs | Yes No | Number of children _______________ | Ages____________ |
| Puurisy or Pneumonia | Yes No | Date of first day of last period | ___/___/_____ |
Locomotor-Musculoskeltal: |
Neuro-Psychaitric: |
||
| Varicose veins | Yes No | Have you ever had psychiatric care? | Yes No |
| Weakness of muscles or joints | Yes No | Been advised to see a psychiatrist? | Yes No |
| Any diffuculty in walking | Yes No | Ever have, or had, fainting spells? | Yes No |
| Any pain in calves or buttocks on walking relieved by rest? | Yes No | Convulsions | Yes No |
Hematologic: |
Paralysis | Yes No | |
| Slow to heal after cuts | Yes No | Allergic: |
|
| Blood disease | Yes No | Any allergies, including medication? | Yes No |
| Anemia | Yes No | Endocrine: |
|
| Phlebitis | Yes No | Thyroid disease | Yes No |
| Diffuculty with excessive bleeding aftertooth extraction or surgery? | Yes No | Have you become colder that before or has skin become dryer? | Yes No |
| Have you had abnormal brusing or bleeding? | Yes No | Any change in hat or glove size? | Yes No |
YOUR HEIGHT |
_____ft ____inches | Any change in hair growth? | Yes No |
YOUR WEIGHT |
___________ lbs | Hormone therapy | Yes No |
ALLERGIES & SENSITIVITIES |
||
| Is there a history of skin reaction, other untoward reaction or sickness following injection or oral administration of: | ||
| Check One | What Drug or Food? | |
| Penicillin or other antibotics | Yes No Don't Know | _______________________________ |
| Morphine, Codeine, Demeral, or other | Yes No Don't Know | _______________________________ |
| Novocaine or other anesthetics | Yes No Don't Know | _______________________________ |
| Asprin, empirin or other pain remedies | Yes No Don't Know | _______________________________ |
| Sulfa drugs | Yes No Don't Know | _______________________________ |
| Tetanus antitoxin or other serums | Yes No Don't Know | _______________________________ |
| Adhesive tape | Yes No Don't Know | _______________________________ |
| Idoine or merthiolate | Yes No Don't Know | _______________________________ |
| Any other drug or medication | Yes No Don't Know | _______________________________ |
| Any food, such as eggs, milk or chocolate | Yes No Don't Know | _______________________________ |
Drugs Recently Taken: |
||
Within the past six months has patient taken: |
||
| Cortisone | Yes No Don't Know | |
| ACTH | Yes No Don't Know | |
| Anticoagulants | Yes No Don't Know | |
| Tranquilizers | Yes No Don't Know | |
| Hypotensives (high blood pressure medicines) | Yes No Don't Know | |
| Has patient ever received treatment for: | ||
| Asthma, rheumatismor rheumatic fever? | Yes No Don't Know | |
| Asprin | Yes No Don't Know | |
| Source of information, if other than patient: |
__________________________________________________________________ |
|
| Nature of person aquiring this information: |
__________________________________________________________________ |
|
________________________________________ Doctor |
______/_____/_____ Date |
________________________________________________ Signature of patient |
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