HISTORY AND PHYSICAL (Please complete carefully and thoroughly)
NAME: ___________________________________ AGE__________ BIRTH DATE________________
HEIGHT ___________________WEIGHT________________
REVIEW OF SYMPTOMS (circle any of these symptoms you many have had in the past year)
GENERAL:
Poor appetite, weight change
HEAD:
Headaches
EYES:
Blurred or double vision
THROAT:
Chronic sore throats, difficulty swallowing
MOUTH:
Loose of false teeth, dental problems
LUNGS:
Shortness of breath, chronic cough
Weakness in paralysis
HEART:
HAVE YOU EVER HAD A BLOOD TRANSFUSION?
NO
YES
ABDOMEN:
GU:
NEUROLOGIC
Chest Pain, heart pounding, swollen ankles/hands
Nausea, vomiting, change in bowel habits,
blood in stool, recurrent indigestion, abdomen pain
Frequent urination, pain or burning with urination
Headaches, numbness/tingling in hands/feet
frequent falls, dizziness, burning in hands or feet
PAST MEDICAL HISTORY (circle if you have ever had any of the following)
Anemia
Epilepsy/Seizure
Lung Disease/COPD
Diabetes/Adult/Child
Anxiety/Depression
Fibromyalgia
Multiple Sclerosis
Insulin Dependent
Arthritis
Hard of Hearing
Nervous Breakdown
Emphysema
Blood Clots in Legs/Lungs
Heart Disease
Pneumonia
Jaundice
Bowel Disease
Hernia-Hiatal/Other
Polio
Kidney Disease
Breast cysts or lumps
Hepatitis
Poor Vision
Liver Disease
Bleeding Disorder
High Blood Pressure
Rheumatic Fever
Tuberculosis
Chronic Bronchitis
High Cholesterol/Triglycerides
Skin Disease
Ulcers
Dizziness
HIV
Thyroid Problems
MRSA
Sleep Apnea
Cancer
Gout
Other____________________________
CARDIAC HISTORY
Have you ever been treated for a heart problem?
YES
NO
Name and Number of cardiologist: __________________________________ Last visit/EKG _________________________________
FAMILY HISTORY
Maternal or Paternal
Blood Disease
Heart Attack
Cancer
Diabetes
Tuberculosis
Problems with Anesthesia
Lung Disease
Birth Defects
Liver Disease
Kidney Disease
History of Drug or Alcohol abuse?
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YES NO
SOCIAL HISTORY
Do you smoke cigarettes?
Packs/Day
Have you ever smoked cigarettes?
When did you stop?
Do you chew tobacco?
Do you use “street” drugs?
Do you drink alcohol daily?
Have you ever taken Cortisone?
Any problems with Anesthesia?
Are you LEFT or RIGHT handed?
YES NO
______
YES NO
______
YES NO
YES NO
YES NO
YES NO
YES NO
R
L
LIST ALL MEDICATIONS YOU ARE CURRENTLY
Do you use medical marijuana?
YES NO
TAKING OR HAVE TAKEN OVER THE PAST YEAR
LIST ALL KNOWN ALLERGIES/REACTIONS
Name/Strength/Frequency
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
LIST ALL MAJOR OPERATIONS, INJURIES, OR CHRONIC ILLNESSES
DATE
TYPE OF INJURY OR ILLNESS
______________
__________________________________________________________________
______________
__________________________________________________________________