UPDATED MEDICAL HISTORY FORM: Established Patient
NAME:_____________________________________________ DATE: _________________
DOB: ______________
GENDER: __________
AGE: _________
HEALTH HISTORY UPDATES
(Since your last visit)
New allergies or reactions to food, medication, other:
New Injuries/Surgeries/Conditions/Hospitalizations:
New Medications (prescription, OTC, Vitamins) and Dosages:
Family Members with New Medical Problems/History:
New Provider or Specialists:
Concerning Exposures or Injuries:
HEALTH MAINTENANCE SCREENINGS SINCE LAST VISIT
*Screening Labs
Date/Location:
*Stool Guaiac
Date/Location:
*Colonoscopy/Sigmoid
Date/Location:
*Vision Exam
Date/Location:
*Mammogram
Date/Location:
*Pap Smear
Date/Location:
*Dental Exam
Date/Location:
SOCIAL HISTORY UPDATES/CHANGES
Marital Status:________ Work Changes:__________________ Tobacco Use: Yes/No (chew or smoke)
Alcohol Use: Never/Occas/Weekly/Daily Caffeine Use: Never/Occas/Weekly/Daily Drug Use: Yes/No
What are your goals for your health:
In the next year:
In the next five years:
REVIEW OF SYSTEMS
Please mark the box next to the symptom(s) you are currently experiencing
SKIN
Rash
Sores
Changes with a Mole
Itching/Dryness
Hair and Nail Changes
EARS
Loss/decrease of hearing
Drainage from ears
Ringing
Earache
EYES
Blurry Vision
Drainage from eyes
Pain
Vision loss/changes
Flashing lights/Dots
LUNGS
Cough
Difficulty/Painful
breathing
Coughing up blood
Wheezing
HEART
Heart Murmur/Palpitations
Chest pains/discomfort/
Tightness
Swelling
Leg pain when walking
SKELETON
Pain in joints
Stiffness
GASTRO
Change in appetite
Problems swallowing
Abdominal
Wheezing
Nausea/Diarrhea
Change in bowel habits
Rectal Bleeding
Constipation
URINARY
Frequency
Urgency
Burning or Pain
Blood in Urine
Incontinence
Change in Urinary strength
NEUROLOGIC
Dizziness
Fainting
Seizures
Weakness
Numbness
Tingling
Tremor
ENDOCRINE
Heat/Cold Intolerance
Sweating
Thirst
Change in appetite
HEAD
Headaches/Migraines
Neck Pain
Head Injury
PSYCHIATRIC
Nervousness
Stress
Depression
Memory Loss
BREAST
Lump(s)
Pain
Discharge
Tenderness
Color Changes
VAGINAL
Discharge
Hot Flashes
Change in Periods
Itching or Dryness
Pain with Sex
Loss of Sex Drive
Lesions/Sores
PROSTATE
Lump(s)
Pain/Pain with Sex
Lesions/Sores
Loss of Sex Drive
Hernia
Swollen joints
Back Pain