NAME:___________________________________ DOB:___/___/___ TODAY’S DATE:___/___/___
IF female is there any chance that you might be pregnant? YES or NO Date of LMP___/___/___ or N/A
Please list the medications you are currently taking, their dosages, and how many times per day you
take them:
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Do you have any ALLERGIES or intolerances to drugs, latex, food, insects, etc? YES or NO If YES, provide
a description of each allergy including the type of reaction:
_____________________________________________________________________________________
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Medical History:
_____________________________________________________________________________________
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Family History:
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Do you use Tobacco? __________
Do you smoke? __________ How many a day? __________ How many years? __________ Have you
attempted to quit? __________
Do you drink? __________ How often (please circle)? Social
Occasional
What do you drink (please circle)? Beer
Wine
Liquor
Light
Heavy
Surgical history:
_____________________________________________________________________________________
_____________________________________________________________________________________
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Immunization History (Please include dates):
_____________________________________________________________________________________
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Reason for today’s visit:
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Constitutional:
Chills?
Decline in Health?
Fatigue?
Fever?
Head:
Dizziness?
Fainting?
Headaches?
Eyes:
Discharge?
Excessive tearing?
Redness?
Vision loss?
Eye pain?
Infections?
Recent injury?
Pain? Which ear?
Ringing in ears?
Nose:
Discharge?
Nasal obstruction?
Nosebleeds?
Ears:
Discharge?
Hearing aid?
Hearing
impairment?
Mouth:
Bleeding gums?
Postnasal drip?
Tongue burning?
Voice changes?
Lumps?
Tenderness?
Tonsils enlarged?
Wheezing?
Short of breath?
Is cough
productive?
Chest pain?
Palpitations?
Varicose veins?
Leg pain-walking?
Short of breathexertion?
Short of breathlying flat?
Short of breathsleeping?
Swelling of legs?
Abdominal pain?
Constipation?
Diarrhea?
Heartburn?
Rectal bleeding?
Change in stool
consistency?
Decreased
appetite?
Hemorrhoids?
Nausea?
Rectal pain?
Swallowing
problems?
Vomiting?
Vomiting blood?
Joint pain?
Back problems?
Joint stiffness?
Muscle cramps?
Muscle stiffness?
Restricted motion?
Weakness?
Throat/Neck:
Frequent sore
throat?
Respiratory:
Cough?
Cardiovascular:
Gastrointestinal:
Musculoskeletal:
Psychiatric:
Depression?
Behavioral
changes?
Disturbing
thoughts?
Excessive stress?
Hallucinations?
Memory loss?
Mood changes?
Nervousness?
Lumps?
Pain?
Tenderness?
Dryness?
Hair texture
change?
Hives?
Mole increased
size?
Dizziness?
Headaches?
Memory loss?
Numbness?
Weight loss?
Increased thirst?
Cold intolerance?
Sweats?
Excessive urination?
Fatigue?
Bleeding easily?
Easy bruisability?
Lumps?
Swollen glands?
Coughing?
Hives?
Itchy eyes?
Itchy nose?
Recurrent
infections?
Runny nose?
Sneezing?
Stuffy nose?
Watery eyes?
Breast:
Discharge?
Skin:
Itching?
Neurological:
Loss of
consciousness?
Unsteady gait?
Endocrine:
Weight gain?
Heat intolerance?
Hematologic/Lymph:
Anemia?
Allergic/Immunologic?
Urinary:
Awakening to
urinate?
Incontinence?
Blood in urine?
Burning?
Excessive urination?
Frequency?
Infections?
Pain on urination?
Urgency?
Hernias?
Sexual problems?
Lesions?
Venereal disease?
Pain?
Prostate problems?
Bleeding between
periods?
Change in periodsduration?
Change in periodflow?
Change in periodsinterval?
Discharge?
Itching?
Lesions?
Menstrual pain?
Pain on
intercourse?
Postmenopausal
bleeding?
Male genitalia:
Discharge?
Scrotal masses?
Female genitalia:
Sexual problems?