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