WASHINGTON UNIVERSITY SCHOOL OF MEDICINE
Subject Initials: ____________________
Visit Name/Number: _______________
Investigator: ______________________
Subject ID Number: ____________________
Date of Visit:
_____/_____/_____
HRPO # ______________________________
MEDICAL HISTORY
*Circle conditions which are part of subject’s medical history
HEAD:
headache
memory difficulty
seizures
dizziness
head/facial trauma
lightheadedness
confusion
clenching/grinding teeth
concussion
hair loss
other (describe): _______________________________________________________________________
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EYES:
glasses/contacts
double vision
near sighted
blurred vision
astigmatism
far sighted
glaucoma
detached retina
cataracts
excessive tearing
blindness
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
EARS:
ear infections
excessive wax
discharge
perforated eardrum
tinnitus
hearing loss
hearing aid
cerumen impaction
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
NOSE:
nasal polyps
altered smell
sinus polyps
allergic rhinitis
seasonal allergies
snoring
nasal obstruction/blockage
nosebleeds
nasal discharge
sinusitis
deviated septum
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
THROAT: tonsillectomy
sore throats
mouth lesions/ulcers/cold sores
tenderness/swelling in neck or behind ears
difficulty chewing or swallowing
swollen glands
other (describe): _______________________________________________________________________
Feb. 2014
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RESPIRATORY:
pneumonia
Tuberculosis (TB)
asbestos exposure
COPD
wheezing
pleural effusion
emphysema
pleurisy
rib fracture
chronic cough
Smoking History: Never Smoked
Tobacco Use:
Asthma
chronic/acute bronchitis
orthopnea
night sweats
Ex-Smoker (quit at least one month ago)
Occasional (less than every other day)
dyspnea
Current smoker
Light (1-2 cig, 1 cigar, pipe every day)
Moderate: (3-10 cig, 2-3 cigars, pipes daily)
Heavy (>11 cig, >4 cigars, pipes daily)
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
CARDIOVASCULAR:
chest pain/jaw pain/pain down arms (angina)
congestive heart failure
rheumatic fever
pacemaker
palpitations
murmur
hypertension
PVD
arrhythmias
PAD
at rest/with exertion
dizziness/passing out/syncope
MI
stroke
mitral/tricuspid valve regurgitation/stenosis/prolapse
peripheral edema
aneurysm
atherosclerosis
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
GASTROINTESTINAL:
weight loss
blood in stools
nausea
weight gain
vomiting
ulcers
vomiting blood
irritable bowel syndrome
dysphagia
constipation
indigestion
sour taste in mouth
Crohn’s disease
Alcohol Classification: Never drank
Alcohol Use:
diarrhea
anorexia
tarry stools
spastic colon
stomach disease
jaundice
polyps
GERD
gastric bypass
ex-drinker (quit at least 1 month ago)
Occasional (less than once a week)
bulimia
Currently drinks
Light (1-2 beers, wine or liquor each week)
Moderate (3 – 7 beers, wine, or liquor each week)
Heavy (>8 beers, wine or liquor each week)
other (describe): _______________________________________________________________________
Feb. 2014
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HEPATOBILIARY:
gallstones
clay colored stools
Hepatitis A
cirrhosis
Hepatitis B
metal taste in mouth
Hepatitis C
jaundice
varices
pancreatitis
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
UROLOGY:
nocturia
low back pain
frequency
incontinence
frequent urinary infections
testicular lump
prostate disease penile discharge
hernia
vaginal discharge
urgency
hesitancy
kidney/bladder stones
painful urination
STD
facial edema
oliguria
impotence
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
REPRODUCTION:
age at menopause ______
LMP ________________
# pregnancies _____
# premature births ______
breast cancer
breast asymmetry
abnormal mammogram
# live births _____
# miscarriages ______
hysterectomy, if yes, what age ______ ovaries removed also? ______
Hormone replacement therapy
nipple discharge
age at first menstrual period _____ currently nursing
STD
breast tenderness
fibrocystic disease
dysmenorrhea
breast mass
abnormal pap smear
BCP
current chance of pregnancy? _________
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
NEUROLOGY/PSYCHIATRY:
shingles
stiff neck
Alzheimer’s disease
insomnia
ADD
Nervousness
numbness/tingling in extremities
impaired cranial nerve functioning
brain cancer
ADHD
brain aneurysm
drug addiction
impaired memory
depression
alcohol addiction
bipolar
restlessness
TIA
anxiety
chronic fatigue syndrome
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
Feb. 2014
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BLOOD / LYMPHATIC:
blood transfusion
high cholesterol
anemia
leukemia acute/chronic
blood clots
iron deficiency
B12 deficiency
cancer
anticoagulant use
lymph node enlargement
sickle cell disease
AIDS/HIV
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
ENDOCRINE / METABOLIC:
hypo/hyperthyroidism
diabetes type I/ type II
renal dialysis
hypoglycemia
adrenal excess/insufficiency
hirsutism
pituitary tumor
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
MUSCULOSKELETAL:
leg cramps
arthritis/gout
bone/joint pain
joint swelling
limited range of motion
joint injury
muscle weakness
osteoporosis artificial joint
numbness
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
SKIN:
hives
mole/pigmentation
rash
eczema
skin cancer
dermatitis
puritis
cold sores/fever blisters
psoriasis
change in
hair loss
other (describe): _______________________________________________________________________
_____________________________________________________________________________________
SURGICAL HISTORY: __________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
ALLERGIES: (INCLUDE REACTION) __________________________________________________
Feb. 2014
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ANY SERIOUS ILLNESS NOT LISTED ABOVE: _________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
NOTES: ______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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SIGNATURE: __________________________________________________________________________
DATE: ______________________________________
Feb. 2014
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