Patient Name:
____________________________________________________________
Date:
___________________
Family History
-
Father:
Please shade in all circles completely
O Alive O Deceased
O Inherited Disease O Cancer O Diabetes O Epilepsy O Heart Trouble O Kidney Trouble
O SickleCell Disease O Mental Illness O Stroke O Tuberculosis
Mother:
O Bleeding Problems
O Alive O Deceased
O Inherited Disease O Cancer O Diabetes O Epilepsy O Heart Trouble O Kidney Trouble
O SickleCell Disease O Mental Illness O Stroke O Tuberculosis
Paternal Grandmother:
O Bleeding Problems
O Alive O Deceased
O Inherited Disease O Cancer O Diabetes O Epilepsy O Heart Trouble O Kidney Trouble
O SickleCell Disease O Mental Illness O Stroke O Tuberculosis
Paternal Grandfather:
O Bleeding Problems
O Alive O Deceased
O Inherited Disease O Cancer O Diabetes O Epilepsy O Heart Trouble O Kidney Trouble
O SickleCell Disease O Mental Illness O Stroke O Tuberculosis
Maternal Grandmother:
O Bleeding Problems
O Alive O Deceased
O Inherited Disease O Cancer O Diabetes O Epilepsy O Heart Trouble O Kidney Trouble
O SickleCell Disease O Mental Illness O Stroke O Tuberculosis
Maternal Grandfather:
O Bleeding Problems
O Alive O Deceased
O Inherited Disease O Cancer O Diabetes O Epilepsy O Heart Trouble O Kidney Trouble
O SickleCell Disease O Mental Illness O Stroke O Tuberculosis
O Bleeding Problems
2015 WEST MAIN STREET, SUITE 100 STAMFORD CONNECTICUT 06902 T 203 863 4588 F 203 863 4587
Social History
Are you a Smoker?
Do you drink alcohol?
O Yes O No
If Yes, how often?
O Yes O No
If Yes, How often?
O Less than 10 drinks a year
O Less than a pack.
O 2 – 3 drinks a month
O About a pack a day. (20 Cigarettes)
O 3 – 5 drinks a week
O More than a pack a day.
O More than 5 drinks a week
If Yes, For how long?
If Yes, For how long?
O Less than 5 years.
O Less than 5 years.
O 5 – 10 years.
O 5 – 10 years
O More than 10 years.
O More than 10 Years
Do you drink caffeine?
If Yes, How often?
O Yes O No
Do you use Street Drugs?
O Yes O No
If Yes, What kinds?
O 2 – 3 drinks a month
O 3 – 5 drinks a week
______________________________
O Daily
O Multiple drinks daily
______________________________
If Yes, For how long?
O Less than 5 years.
______________________________
O 5 – 10 years
O More than 10 Years
For how long?
______________________________
What is your Occupation?
2015 WEST MAIN STREET, SUITE 100 STAMFORD CONNECTICUT 06902 T 203 863 4588 F 203 863 4587
Please shade in all circles completely
Past Medical History
Hypertension
O Yes O No
General
Stroke
O Yes O No
Fatigue
O Yes O No
Diabetes Mellitus
O Yes O No
Lightheadedness
O Yes O No
Atrial fibrillation
O Yes O No
Imbalance
O Yes O No
Fibromyalgia
O Yes O No
Vertigo (spinning)
O Yes O No
Neuropathy
O Yes O No
Epilepsy
O Yes O No
ENT/respiratory
Lyme disease
O Yes O No
Ringing in ears
O Yes O No
Surgery
O Yes O No
Sinus problems
O Yes O No
If yes, Date of Surgery:
Gastroenterology
----------------------------------------------------------
Diarrhea
O Yes O No
Constipation
O Yes O No
Nausea
O Yes O No
Bloating after meals
O Yes O No
Psychology
Depression
O Yes O No
Neurology
Tension/stress
O Yes O No
Headache
O Yes O No
Sleep disturbances
O Yes O No
Tingling numbness
O Yes O No
Anxiety
O Yes O No
Memory problems
O Yes O No
Tremors
O Yes O No
Disorientation
O Yes O No
Musculoskeletal
Neck pain
O Yes O No
Back pain
O Yes O No
Opthalmology
Muscle cramping
O Yes O No
Blurring of vision
Dermatology
Rash
O Yes O No
Hematology
O Yes O No
Easy bruising
O Yes O No
Cardiology
Chest pain
O Yes
O No
Palpitations
O Yes
O No
2015 WEST MAIN STREET, SUITE 100 STAMFORD CONNECTICUT 06902 T 203 863 4588 F 203 863 4587