Patient Name: ______________________________________ Today’s Date: _________ Age: _______ Birth date:___________
Date of last physical examination ________ what is your reason for visit? ______________________________________
Symptoms: Check symptoms you are currently concerned with:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
GENERAL
o
Chills
o
Depression
o
Dizziness
o
Fainting
o
Fever
o
Forgetfulness
o
Headache
o
Loss of sleep
o
Loss of weight
o
Nervousness
o
Sweats
o
Muscle/Joint/Bone: o
weakness/numbness in: o
Arms
o
Back
o
Feet
o
Hands
o
Hips
o
Legs
o
Neck
o
Shoulders
o
Genito-Urinary
o
Blood in urine
o
Frequent urination
o
Lack of bladder control o
Painful urination
o
Gastrointestinal
o
Appetite poor
o
Bowel changes
o
Constipation
o
Diarrhea
o
Excessive thirst
o
Hemorrhoids
o
Indigestion
o
Nausea
o
Rectal bleeding
o
Stomach pain
o
Vomiting
Vomiting blood
Cardiovascular
Chest pain
High blood pressure
Irregular heart beat
Rapid heart beat
Swelling of ankles
Varicose veins
Eye, ear, nose, throat
Bleeding gums
Blurred vision
Difficulty swallowing
Double vision
Ear discharge
Hay fever
Hoarseness
Loss of hearing
Nosebleeds
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Persistent cough
Ringing in ears
Sinus problems
Visions - Flashes
Skin
Bruise easily
Hives
Itching
Changes in moles
Sore that won’t heal
MEN ONLY
Breast lump
Erection difficulties
Lump in testicles
Penis discharge
Sore on penis
Other
WOMEN ONLY
Bleeding between
periods
Breast lump
Extreme menstrual
pain
Hot flashes
Nipple discharge
Painful intercourse
Vaginal discharge
Other
o
o
o
o
o
o
o
o
o
Last menstrual period:
___/____/________
Last Pap Smear: ___/___/____
Have you had a
mammogram? Y / N
Are you pregnant? Y / N
Number of children: ___
List medications you are currently taking: _________________________________________________________________________________________________
Pharmacy Name: ___________________________Phone: __________________
Allergies: _______________________________________________________
Family History: Check if your blood relatives had any of the following:
Disease
Relationship to you
Arthritis, Gout
________________
Asthma, Hay Fever ________________
Cancer and type ________________
Tuberculosis
________________
Disease
Relationship to you
Chemical dependency _________________
Death before age 60
_________________
Diabetes
_________________
Other
_________________
Hospitalizations and pregnancies:
Year
Hospital
Reason and Outcome
_______ ____________________ __________________________________________
_______ ____________________ __________________________________________
_______ ____________________ __________________________________________
_______ ____________________ __________________________________________
Year
______
______
______
______
Disease
Heart disease, Strokes
High Blood Pressure
Kidney Disease
Relationship to you
________________
________________
________________
Hospital Reason and Outcome
___________________ ______________________________________________
___________________ ______________________________________________
___________________ ______________________________________________
___________________ ______________________________________________
Health Habits: Check which you use & how much
Alcohol: _______ Caffeine: _______ Tobacco: _______ Street Drugs: ________Other: _________
Occupation: ________________________________________
Check if your work exposes you to: Stress:________ Heavy Lifting: ________ Hazardous Substances: __________ Other: _____________
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform
my doctor if I, or my minor child, ever have a change in health.
__________________________________________________________
Signature of Patient Parent, Guardian or Personal Representative
__________________________________________________________
Please print name of Patient, Parent, Guardian or Personal Representative
__________________________________________________________
Reviewed By
__________________________
Date
__________________________
Date
___________________________
Date