SURGEON’S GROUP HEALTH HISTORY FORM
PATIENT NAME _________________________________________________ DATE ________________________
REASON FOR VISIT _____________________________________________________________________________
PAST MEDICAL HISTORY—Please indicate if you have or had any of the following:
_____ Heart attack
_____ Congestive Heart Failure
_____ Angioplasty
_____ Heart Murmur/Valvular Problems
_____ Store of TIA’s
_____ Blood Transfusion
_____ Seizure Disorder
_____ HIV
_____ Tuberculosis/Positive TB Test
_____ Rheumatoid Arthritis
_____ Cystic Fibrosis
_____ Kidney or Bladder Disease
_____ Tattoos
_____ High Blood Pressure
_____ Previous Heart Surgery
_____ Diabetes
_____ Hemophilia/Other Clotting Problems
_____ Hepatitis
_____ Anemia
_____ Migraine Headaches
_____ Asthma or Emphysema
_____ Cancer
_____ High Cholesterol
_____ Body Piercing
_____ Sensitivity to Contrast Material
_____ Difficulty with Anesthesia
_____ Other Illness: __________________________
PAST FAMILY HISTORY—Please indicate which family members have or had any of the following:
_____ High Blood Pressure
_____ Uterine/Ovarian/Breast Cancer
_____ Diabetes
_____ Depression
_____ Colon Cancer
_____ Prostate Cancer
_____ Skin Cancer
_____ Heart Attack or Stroke
_____ Other Illness: __________________________
SOCIAL HISTORY—Please indicate if you do now or ever have:
_____ Smoked or Used Tobacco
Year Quit _______
Quantity________ How Often ______________
_____ Use or Used Alcohol
Quantity ____________
How often ________________
_____ Worked with Hazardous Chemicals
_____ Used Illicit Drugs
ALLERGIES
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MEDICATIONS—Please list current medications including vitamins and herbal supplements
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PHARMACY & LOCATION________________________________________________________________________
TESTS PERFORMED IN THE PAST 12 MONTHS:
_____ EKG/Stress Test
_____ Blood Work
_____ EEG
_____ X-Ray of ______________________________
_____ CT/MRI of _____________________________
_____ Ultrasound of __________________________
_____ Other_________________________________
PREVIOUS SURGERIES
1.
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2.
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3.
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4.
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5.
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6.
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SYSTEMS REVIEW—Check all signs/symptoms that apply to you:
CONSTITUTION
_____ Fever
_____ Chills
_____ Weight loss
_____ Night sweats
_____Malaise/Fatigue _____ Weakness
_____ Diaphoresis (profuse perspiring)
SKIN
_____ Rash
_____ Lesions
_____ Itching
_____Breast mass/lump
HENT
_____ Headaches
_____ Hearing loss
_____ Ear pain
_____ Ear discharge
_____ Nosebleeds
_____ Congestion
_____ Tinnitus (ringing in ears)
EYES
_____ Blurred vision _____ Double vision
_____ Eye pain
_____ Eye discharge
_____ Eye redness
_____ Photophobia (sensitivity to light)
CARDIOVASCULAR
_____ Chest pain
_____ Palpitations
_____ Leg swelling
_____ Orthopnea (shortness of breath)
_____ Claudication (leg cramping)
RESPIRATORY
_____ Cough
_____ Hemoptysis
_____ Wheezing
_____ Sputum production
_____ Shortness of breath
GASTROINTESTINAL
_____ Heartburn
_____ Diarrhea
_____ Blood in stool
_____ Reflux
_____ Abdominal pain
_____ Nausea
_____ Constipation
_____ Melena
_____ Vomiting
GENITOURINARY
_____ Urgency
_____ Frequency
_____ Flank pain
_____ Dysuria (painful urination)
_____ Hematuria (blood in urine)
MUSCULOSKELETAL
_____ Neck pain
_____ Back pain
_____ Myalgia (muscle pain)
_____ Joint pain/swelling
ENDO/HEME/ALLER
_____ Bruises/bleeds easily
_____ Environment allergies
_____ Polydipsia (increased thirst)
NEUROLOGICAL
_____ Dizziness
_____ Tingling
_____ Tremors
_____ Seizures
_____ Sensory change _____ Speech change
_____ Focal weakness
PSYCHIATRIC
_____ Depression
_____ Memory loss
_____ Suicidal ideas
_____ Nervous/anxious
_____ Substance abuse _____ Hallucinations