Name: ___________________________________________________
Are you on Dialysis? No or
Yes – What days?
Date: ____________________________
Mon/Wed/Friday
Tue/Thurs/Sat
Dialysis Phone #: _____________________________________________ How long on dialysis?: _______________________________________
General Questions
Reason for visit: __________________________________________________________________________________________________________
Females – Are you pregnant?
Do you smoke?
Never
Do you drink Alcohol?
No
No or
Yes – Due Date: _____________________________
Former Smoker
or
Yes – Amount per day? ___________________________________
Yes – Amount per day? ___________________________
Past Medical History (ONLY Check ALL that applies to you)
Hepatitis
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HIV
Other: _______________________
Cataract
Glaucoma
Headache
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Hearing loss
Hoarseness
Sinusitis
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Sudden Vision loss
Vertigo
Other: _______________________
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Heart Disease
Heart Bypass
High Blood pressure
Irregular Heart Rhythm
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Pulmonary embolism
Raynaud’s syndrome
Other: _______________________
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COPD (Chronic Obstructive
Pulmonary Disease)
Emphysema
Pneumonia
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Sleep apnea /C PAP
Oxygen use
Other: ____________________
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Gastrointestinal disorder
GERD (Reflux Disease)
Hiatal Hernia
Bowel Obstruction
Irritable Bowel Syndrome
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Hepatitis
Ulcer Disease
Other: _______________________
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Back Issues
Fibromyalgia
Gout
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Osteomyelitis / Bone Infection
Osteoporosis
Other: _______________________
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Hypercholesterolemia
Hyperlipidemia
Hyperthyroidism
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Hypothyroidism
Sickle-cell anemia
General
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HENT
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Cardiovascular
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Angioplasty/Stenting - Heart
Congestive heart failure
Heart Attack
Respiratory
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Asthma
Bronchitis
Gastrointestinal
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Pancreatitis
Appendicitis/Appendectomy
Cholecystitis/ Gallbladder
Constipation
Musculoskeletal
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Arthritis
o Rheumatoid
o Osteoarthritis
Endocrine
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Diabetes – Insulin controlled
Diabetes – Oral Medicine
Diabetes – Diet controlled
Neurologic/Psychiatric
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Alzheimer’s disease
Anxiety disorder
Bipolar disorder
Memory loss
Migraine
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Multiple sclerosis
Neuropathy
Parkinson’s disease
Seizure disorder
Stroke
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Transient ischemic attack
(Mini Stroke)
Other: ____________________
Cellulitis & Abscess
Pressure ulcer
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Swelling
Impetigo
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Lymphedema
Psorarisis
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Blood in urine
Kidney Stone
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Other: _______________________
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PAD ( legs)
Thoracic aneurysm
Varicose veins / Spider veins
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Other: _______________________
Skin
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Genitourinary
Kidney Failure
Bladder Infection
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Vascular
Abdominal aortic aneurysm
Carotid Blockage
Leg swelling / DVT
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Past Surgical History (Please check all that apply to you)
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Appendectomy
Back Surgery
Bowel Obstruction
Breast Surgery
o Type: _______________
Cataract Surgery
Cholecystectomy (Removal of
Gallbladder)
Colonoscopy
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Past Vascular Surgery
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Carotid Endarterectomy
Lower Extremity Bypass
Aortic Aneurysm
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Colon - Type: ______________
C-section
Heart Surgery
o Type:________________
Hemorrhoidectomy
Hernia Surgery
o Type: ______________
Hysterectomy
Leg amputation
Varicose vein operations
Balloon Angioplasty/Stents
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Lung Surgery
o Type: ______________
Orthopedic Surgery
o Type: ______________
Thyroid Surgery
Tubal Ligation
Other Surgery:
__________________________
Other: ____________________
Family Medical History (Please list any Significant Illnesses such as Cancer, Diabetes, Heart Disease or Stroke)
Alive
FATHER
MOTHER
BROTHERS
SISTER
Deceased
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Medical Disorder
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Please check all that have occurred in any of your BLOOD RELATIVES:
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Aortic Aneurysm
Diabetes
□
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Heart Disease
High Blood Pressure
_______________________________________________________________________
PATIENT SIGNATURE
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High Cholesterol
Stroke
______________________________
DATE
Patient Name: _______________________Date:_______________
Allergies (Please do not leave blank)
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Adhesive / Tape
Aspirin
Codeine
Latex
Local Anesthesia
Penicillin
Lortab/Norco
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Demerol
Iodine
Morphine
Sulfa
X-Ray dye
Other Allergies: _____________________________
No Known Allergies
Medication List
Please list any BLOOD THINNERS that you are currently taking:
_________________________________________________________________________________________________________________________
Please list ALL medications that you are currently taking or provide us with a list to copy:
___________________________________
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Revised – 4.30.14