Name: ___________________________
Date of Birth: _________________________
DETAILED PATIENT INFORMATION
Please list any medical problems/ diseases that you have:
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Please list all medications, herbs, vitamins and over-the-counter products you are taking:
Name
Dose/Strength
How often you take it
790 Church Street, Suite 250, Marietta GA 30060 Ph: 678-797-8201 Fax: 678-290-8325
Name: ___________________________
Date of Birth: _________________________
Please list all allergies to medications, foods, chemicals, plants and the reactions you have:
Allergy
Reaction
FAMILY HISTORY
Please list all family members including mother, father, sisters, and brothers:
 Check here if adopted
Family
member
Name
Medical Problems
Age
Deceased
Any diseases/illnesses that run in the family (Cancer, Diabetes, Heart Disease, etc):
_____________________________
_____________________________________
_____________________________
_____________________________________
_____________________________
_____________________________________
2
Name: ___________________________
Date of Birth: _________________________
SURGICAL HISTORY
Please list all surgeries or procedures you have had done:
Date
Type of
Surgery/Procedure
Reason for
Procedure
Hospital
Name of
Surgeon
Please list all medical specialists that you see:
Name of Doctor
Specialty
3
Name: ___________________________
Date of Birth: _________________________
SOCIAL HISTORY
Name: _________________________
Date of Birth: _______________________
Birthplace: ______________________
Level of education completed: __________
What you do for work: ____________________________________________________
Marital Status
Current status:
 Divorced  Married
 Single
 Widowed
Do you live alone:
 Yes  No
Previously widowed:  Yes  No
Previously divorced:  Yes  No
Children
 Yes
 No
Number of sons: ________________
Number of daughters: ___________________
Tobacco
Are you a smoker:  Yes  No  Former Passive smoker exposure:
 Yes  No
Type: _______________________
Packs/day ___________________________
Years smoked: ______
Year Quit: _____
Ever tried to quit:
 Yes  No
Caffeine
Do you drink caffeine:
Type:
 Chocolate
 Yes
 Coffee
Alcohol
Do you drink alcohol:
Type:
 Beer
Frequency: ____________
 Yes
 No
 Formerly  Year Quit: ________
 Hard Liquor
 Wine
Amount: ___________
Last drink: _______________
 No
 Soda
 Tablets
 Tea
Lifestyle
Activity level:
 Sedentary  Moderate  Vigorous
Health club member:  Now
 Previously  Never
Type of exercise: __________________________________________________________
Exercise Frequency: _______________________ Hours/week: ___________________
Hobbies/Activities: ________________________________________________________
Specific type of diet:  Low fat
 Low carb  Diabetic
 Weight watchers
Animals in the home  Yes
 No
Type: __________________________
Are you the one who cleans up after the animal:
 Yes
 No
4
Name: ___________________________
Date of Birth: _________________________
Recent Travel
Any recent travel out of the state
 Yes  No Where: ________________________
Any recent travel out of the country  Yes  No Where: ________________________
Safety
Are there smoke detectors in the home?
Are there carbon monoxide detectors in the home?
Is there radon in the home?
Do you have firearms in the home?
Do you wear a seatbelt?
 Yes
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 No
Advanced Directives in Place
Mark the advanced directives that you currently have in place:
 None  DNR
 Living Will
 Durable Power of Attorney  HC Proxy
Do you agree to a transfusion?
 Yes
 No
5
Name: ___________________________
Date of Birth: _________________________
HEALTH MAINTENANCE
Please fill in the date of your most recent health maintenance event (if applicable):
Event
Date of Last
Colonoscopy/ GI procedure
Stress test/ Cardiac procedure
Echocardiogram
Eye exam
Skin exam
Mammogram/ Breast exam
Pap-smear
PSA/ Prostate exam
Rectal exam/ Stool cards/ FOBT
Bone Density
Vaccine/ Immunization
Tetanus (Td)
Pneumonia vaccine
Flu vaccine
Hepatitis A vaccine
Hepatitis B vaccine
Date of Last
TB/ PPD (Tuberculosis screening)
MMR (Measles, Mumps & Rubella)
Zostavax
Infectious Disease History
Do you have any history of blood/ blood product transfusion? If so, when and for what reason?
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________
6
Name: ___________________________
Date of Birth: _________________________
Do you have any history of tick bites, Lyme disease, Rocky Mountain Spotted Fever, or Ehrlichiosis? If so,
please explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________
Have you ever had a positive PPD test (Tuberculosis screening)? If so, what happened as a result of that
positive test?
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________
Any concern for possible HIV infection? If so, please explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________
Gynecological History (Females)
Number of Number
Number
Pregnancies of
of CPremature Sections
Births
Number of
Ectopic
Pregnancies
Number
of Vaginal
Births
Number of
Miscarriages
Number
of Life
Births
Number
of Births
at Term
Number of
Children
Currently
Living
Number of
Abortions
 Check here if currently pregnant
7
Name: ___________________________
Date of Birth: _________________________
REVIEW OF SYSTEMS
Have you experienced any of the following symptoms in the past month?
CONSTITUTIONAL
Activity change
Chills
Decreased appetite
Fatigue
Fever
Insomnia
Irritability
Malaise/ feeling unwell
Night sweats
Abnormal paleness
Weakness
Weight gain
Weight loss
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
HEENT
Headache
Eye burning
Double vision
Eye discharge/ drainage
Eye dryness
Foreign body sensation
Eye itching
Rapid eye movements
Eye pain
Sensitivity to light
Eye redness
Visual halloes or blind spots
Spots/ floaters
Tearing
Glasses
Contacts
Visual Loss
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
HEENT continued…
Radical keratotomy
Lasik
Last eye exam
Ear discharge
Cerumen/ ear wax
Ear fullness
Hearing loss
Noise exposure
Ear pain
Tinnitus/ ringing in the ears
Vertigo/ dizziness
NOSE AND SINUS
Decreased smell
Nasal discharge/ drainage
Nose bleeds
Facial pain
Infections
Nasal congestion
Sneezing
No Yes
No Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
8
Name: ___________________________
THROAT AND MOUTH
Taste change
No
Voice change
No
Cold sores
No
Difficulty swallowing
No
Hoarseness
No
Lump sensation
No
Pain when swallowing
No
Post nasal drip
No
Sore tongue/ tongue lesions
No
Sore throat
No
Tooth pain/ dentures/ plates
No
RESPIRATORY/ THORAX
Rapid breathing
No
Cough
No
Chest pain
No
Frequent respiratory
No
infections
Coughing up blood
No
Known TB exposure
No
Positive PPD/ TB test
No
Pain with breathing “stitch” No
Shortness of breath
No
Wheezing
No
CARDIOVASCULAR
Chest pain
Shortness of breath at rest
Shortness of breath on exertion
Sleep sitting up to breathe
Shortness of breath at nightcauses awakening
Swelling of hands and legs
Nighttime urination
Palpitations/ rapid heart beat
Passing out
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Date of Birth: _________________________
VASCULAR
Cramping in legs when walking
Blueing of the hands/ feet
Flushing or redness of hands/ feet
Cool extremities
Swelling of hands, feet or legs
Pain in extremities
Ulcers in legs, feet and arms
Varicose veins
Blood clots
GASTROINTESTINAL
Abdominal mass/ growth
Abdominal pain
Altered bowel habits- change
from normal
Not eating or poor appetite
Black, tarry stools
Bloating and feeling of fullness
Blood in stool
Constipation
Diarrhea
Difficult or painful swallowing
Flatulence/ gas
Jaundice/ yellow/ history of
hepatitis
Indigestion/ heartburn
Throwing up blood
Nausea
Weight loss
Hemorrhoids
Rectal bleeding
Reflux
Vomiting
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No Yes
No Yes
No Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No Yes
No Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
9
Name: ___________________________
GENITOURINARY
Back pain/ flank/ side pain
Change in urine color/ cloudy
urine
Urgency to urinate
Decreased stream or low
urine output
Pain when urinating
Foul urine odor
Urinating frequently
Mass in groin
Blood in urine
Hesitancy or difficulty
urinating
Urine leakage/ incontinence
History of passing a kidney
stone
Urgency to urinate
WOMEN TO COMPLETE
Age of first period
Last menstrual period
Frequency of menstrual cycles
Are you post-menopausal?
Are you on hormones?
Have you previously used
hormones?
Have you ever used birth control?
Have you ever had an abnormal
pap?
Do you do self breast exams?
Lack of libido
Nipple discharge
Breast lumps
Pain with sexual intercourse
History of uterine fibroids
Problems with infertility
Ovarian cysts
Sexual dysfunction
Vaginal itching
Vaginal discharge
No Yes
No Yes
No Yes
No Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No Yes
No
Yes
No
Yes
METABOLIC/ ENDOCRINE
Voice changes
Cold intolerance/ feeling cold
Heat intolerance/ feeling hot
Hair loss
Coarse hair
Abnormal glucose/blood sugar
tests
Abnormal fat distribution
Abnormal hair distribution
Chronically overweight
Chronically underweight
Darkening of skin
History of gout
Excessive perspiration
Excessive hunger or thirst
Generalized weakness
Gestational diabetes
Goiter
Gynecomastia/ male breast
enlargement
Low sugar reactions
Increase in size of feet/ hands
Date of Birth: _________________________
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
MEN
TO
COM
PLE
TE
Are you circumcised?
erectile pain
Penile discharge
Blood in your stream
Scrotum/ testicular pain
Scrotum/ testicular mass
Hydrocele/ fluid around testes
History of Herpes Genitalia
Problems with fertility
Have you ever been treated
for a sexually transmitted
disease?
Describe your sexual function
Normal
Decreased
No
No
No
Yes
Yes
Yes
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
10
Name: ___________________________
NEURO/ PSYCHIATRIC
Language disorder/ Difficulty
talking
Unclear pronunciation
Focal weakness
Difficulty walking
Headaches
Incontinence
In-coordination
Lightheadedness/ dizziness
Loss of consciousness/
fainting
Memory loss
Tingling/ numbness
Seizures
Speech changes
Tremors
Vertigo/ Hx of Meniere’s
Visual changes
Lack of concentration
Do you have any anxiety?
Do you feel fearful?
Do you feel excessively
happy?
Do you feel paranoid?
MUSCULOSKELETAL
No Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No Yes
DERMATOLOGIC
Acne
Contact allergies
Hx of excessive sun exposure
Frequent skin infections
Hair loss
Women: facial hair
Nail changes (brittle)
Change in skin color
Severe itching
Excessive sweating
Sensitivity to light
Rash
Skin lesions: tags, moles,
freckles, birthmarks
Date of Birth: _________________________
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Back pain- neck, mid, low back
Bone/ joint swelling or pain
Hands/ wrist/ elbow shoulder/
hips/ feet/ ankle swelling or
pain
Muscle pain/ weakness
No
No
No
Yes
Yes
Yes
No
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
Yes
No
No
No
Yes
Yes
Yes
No
Yes
HEMATOLOGIC
Easy bruising
Easy bleeding
History of blood clots
Anemia or low blood count
Swollen lymph nodes
IMMUNOLOGIC
Asthma
Hay fever
Hives
Anaphylaxis
Contact dermatitis/ rashes/
metal allergy
Food allergies
“Bee” sting allergy
If yes, reaction type:
Environmental allergies: pollen,
pollution
Animals at home
Animals in the work place
Chemicals in the home
If yes, type:
Chemicals in the work place
If yes, type:
11