Date: Name:
Date of Birth:
Indicate if you have suffered from any of the following:
High Blood Pressure Thyroid Disease Seasonal Allergies
High Cholesterol
Heart Disease
Stroke
Cancer
Hormone Abnormalities
Heartburn
Liver Disease
Gastrointestinal Problems
Skin Problems
Epilepsy
Depression/Anxiety
Neurologic Disease
Asthma/ Emphysema
Lung Disease
Diabetes
Kidney Disease
Anemia OTHER:
Glaucoma
Joint Problems
PROCEDURE: DATE:
REACTION: MEDICATION/FOOD:
NAME OF MEDICATION:
DOSAGE: FREQUENCY:

EXAM:
Mammogram
Pap Smear
Colonoscopy
Lipid Panel
BMDS
PSA
VACCINE:
Pneumovax
Flu Shot
Tetanus
Shingles
DATE OF LAST EXAM:
DATE ADMINISTERED:
Marital Status:
Number of Children:
Occupation:
Do you smoke?
Have you ever smoked?
If yes, how many packs per day?
If yes, how many years smoking?
How much alcohol do you drink per week?
Do you use recreational drugs?
Do you exercise regularly?
Are you able to care for your personal needs?
Married / Single / Widowed / Divorced
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Does anyone in your family have the following? If so, list their relationship to you.
RELATIONSHIP: PROBLEM:
Asthma
Arthritis
Bleeding Disorder
Cancer
Depression / Mental Illness
Diabetes
Epilepsy
Gallbladder Disease
Glaucoma
High Cholesterol
High Blood Pressure
Heart Attack
Migraines
Stroke
Tuberculosis
Any other problems not listed:

GENERAL:
In the past six months have you lost over 5 lbs unexpectedly?
Do you have recurrent unexplained fever?
EYES:
Do you have intermittent loss of vision or double vision?
ENT:
Do you have problems with your hearing?
Do you have problems with speech?
Do you have frequent colds?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
Do you have frequent nose bleeds?
HEART:
Do you have chest pain that concerns you?
Do you have episodes of irregular heartbeat?
Are you bothered by dizzy spells?
RESPIRATORY:
Do you have a persistent cough?
Do you get short of breath easily or wheeze?
GI:
Do you have difficulty swallowing food or liquids?
Do you have any weakness or numbness in your arms or legs?
Have you fallen in the last 6 months?
Do you have frequent and/or severe headaches?
PSYCHIATRIC:
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
Have you noted a recent change in appetite?
Do you have abdominal pain that concerns you?
Have you noted black or tarry bowel movements?
Have you noted any change in you bowel habits?
Do you have any unexplained skin rashes?
Do you have any moles that are growing or changing?
NEUROLOGIC:
Have you had a serious head injury or been knocked unconscious?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
GENITOURINARY:
Do you have problems with sexual functions?
Do you have discomfort when you urinate?
Do you get up at night to urinate?
Do you have any pain, lumps, or discharge in your breast?
Do you have any problems with your menstrual periods?
SKELETAL:
Do you have any pain or swelling in your joints?
SKIN:
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
Are you bothered by depression?
Do you have any personal problems you would like to discuss?
Do you feel safe in your home?
ENDOCRINE:
YES / NO
YES / NO
YES / NO
Have you become unusually thirsty recently?
Do you sense room temperature differently from others?
HEMATOLOGIC:
Do you tend to bruise or bleed easily?
YES / NO
YES / NO
YES / NO
IMMUNOLOGIC:
Do you get frequent recurrent infections requiring antibiotics? YES / NO